Medical Charting Errors? What’s in the chart can really be quite a surprise
Patients have an expectation that their medical charts will be free of misinformation or, if it is found, will be corrected ASAP. The faith we place in these medical caches may be misguided as might be the faith we place in those who input the information.
Prior to the evolution of those wonderful, freely shared electronic health records (EHR) which have spread like a fire over a dry forest, our charts were kept in file folders stacked to the ceiling. Some folders may never see the light of day again because they were destroyed in basement storage areas that were flooded. Patients may not have been told about the extent of this damage in the service of keeping them quiet and ignorant. A breach of ethics? I would say so. Done for insurance purposes? Obviously. Patients can’t sue for what they don’t know.
A survey of office-based physicians in 2015 indicated that 80% of them used EHRs in their practice in the field which is estimated to be billing $3.5 trillion yearly. This figure might seem huge, but the estimated cost of $19.5 billion in medical errors and $1 trillion in lost productivity places it in perspective; medical costs are soaring. From where are all these errors emanating? The fact that Medicare will no longer accept paper claims has added to the mix in ways that may compound the problem. Even today not everyone is computer conversant.
For starters, the systems being used vary across fields, facilities and offices. The prize of locking up as many fields, hospitals and offices is like the gold ring on the merry-go-round. Would that mean one platform would have a monopoly and, therefore, create added incentive for hackers? Imagine the treasure trove waiting for the motivated black hat guys and gals.
Paper records were vulnerable to the office environment, including paper lice and plumbing integrity, but EHRs have two similar problems; input errors and insurance reimbursement coding. Coding (ICD-10) is the gold standard for continued, viable existence in the medical field and no one knows that better than hospitals and physicians’ offices.
Errors, however, in either can lead to problems in treatment or insurance reimbursement for the patient in the future. For example, diabetics have a prescribed pharmaceutical protocol which includes blood-pressure-preserving meds but these patients don’t necessarily have hypertension. The coding says they do. Patients with multiple thyroid nodules are often coded as having one, not multiple nodules. There are different codes for a reason. What might that be? And why would a physician struggle with a patient who wants accuracy here?
The errors, once made, have a life of their own and travel through the medical record effortlessly, being picked up and repeated time and time again. Who questions the validity of the record? In an era when “time is money” is more prevalent than ever, no one can check unless they’re doing a major metadata paper for a professional journal. How many have you seen providing this level of insight regarding errors? It might be interesting to do a search.
Pharmacies, thankfully, have software that flags errant prescriptions and warns both the pharmacist and the physician that there might be a problem. EHRs have no such flagging because it depends on judgment and the person doing the data collection for the patient. Collect it inaccurately and it goes in inaccurately and the failure is pinned on the patient forever.
Try to get it corrected and the error may, once again, be repeated by someone else who has access to the file. It can become a futile dance of inaccuracy that engages the self-esteem of the person managing the file and who believes they, and not the patient, are correct in their assessment; not always true.
Even personnel at major medical centers don’t have all the answers, medically speaking. How could they when there’s so much to know and patients may come in with more knowledge about a specific ailment than they possess? “Oh, you’ve been consulting with Dr. Google,” I’ve heard them say. What’s wrong with doing research in preparation for an informed discussion?
Advice: Check your medical records, if you have on-line access and be sure they are accurate. Neglecting to do this after any medical evaluations or procedures can be more than dangerous, they could prove deadly or inordinately expensive. Remember those pre-existing conditions that are receiving so much coverage? How many do you currently have in your chart? Do you know?