The increase of EHR patient portals is fueling an increase in medical record change requests by the patient.
Patient portal implementation, patient EHR access, and the transparency allowed under HIPAA and privacy laws increase patient empowerment when it comes to patient data access, a group of researchers wrote in the Journal of the American Medical Informatics Association (JAMIA).
Although patients have always been able to ask medical records changes, EHRs have made it increasingly easier to view their record and request changes, making these requests much more prevalent.
Using the patient portal, patients can view and request changes to their medical records.
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“Over the last few years, our institution has been tracking amendment requests, and we have noted an increase in the number of formally submitted Problem List requests regarding diagnoses,” wrote Amy Porter, MD, of the Rainbow Center for Comprehensive Care and the corresponding author. “Amendment requests are not always clear-cut; clinicians and patients disagree over whether an amendment accurately reflects the patient’s condition.”
“As patients question the Problem List, clinicians face the ever more frequent challenge of discerning which changes to make and refuse,” Porter continued. “To describe the collaborative process that we have witnessed in our institution by which providers and patients negotiate the Problem List, we have coined the phrase: the cocuration of clinical identity.”
Not only can patients access their medical information through patient portals, but they can also order tests and screenings. Patients also have access to add or remove a diagnosis from a separate interface within the patient portal based on laboratory findings.
“As the physician’s role slides closer to consultant and further from authority, the medical paternalism of the twentieth century falling further into the background of our technology-infused present, where should we draw the line in terms of who holds the power of delineating a patient’s clinical identity?” Porter asked.
The group of researchers said clinicians need to find a balance between problem list accuracy and encouraging patients to engage with their health records.
Although the problem list has its benefits, it also has the potential to be inaccurate due to clinical inefficiency and “copy and paste” issues. It has also become too comprehensive with too much input from both the clinician and the patient, they note.
That said, granting patient data access and assessing medical record change requests can also increase patient engagement and trust between the patient and provider.
“The clinician’s role has already begun to shift, making the physician a consultant who helps to interpret test results or choose a subspecialist, a proceduralist who performs diagnostic and therapeutic interventions that patients cannot do themselves, and a gatekeeper—no longer to the simpler diagnostic tests (eg, ECGs), but to follow-up services including more complex diagnostics, and to referrals,” Porter wrote.
To learn more about this issue, researchers at the Cleveland Clinic have put together a “how to” tool for providers to consider during disputes. It offers ways to tackle requests, provides sample case studies of disputes, recommends steps for engaging patients with disputes, and it notes important nuances for the for the clinician to consider.
“Given the immediacy of the need to answer—or at least deliberate over—such questions in the face of technology-mediated patient EHR engagement, we call for research investigating the challenges of Problem List deliberations,” wrote Porter.
In the future, the team expects collaborations with health systems, EHR vendors, and government agencies to address the Problem List disputes.
“We need qualitative studies of both patient and physician perspectives on why and how the Problem List should be controlled and how that control should be mediated, as well as quantitative studies examining the extent of the challenge across healthcare institutions nationwide,” Porter concluded.
Previous research has signaled patient data access and the right to request medical record changes has been a positive step. A 2016 OpenNotes study revealed that medical record change requests can improve patient safety.
The study published in BMJ Quality and Safety, included 6,225 patients who were given a feedback tool, 44 percent looked at their notes, and roughly 8 percent used the feedback tool. Of that 8 percent, 23 percent voiced concerns about their notes, and 57 percent of those responses were indeed correct, resulting in a change.
Even though it can be a burden for clinicians to respond to patient requests, accuracy in one’s patient portal is vital for ensuring patient safety.
But not only does it protect patient safety, transparency is required under HIPAA, which grants the patient her right to review her medical record and request changes if necessary.
“If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request,” HIPAA states. “If it created the information, it must amend inaccurate or incomplete information.”
Source: EHR Intelligence