I think all patients should monitor their own health care. Do you keep track of your medical records and what is inside them? I do. Why because I feel I know myself better than anyone. It is not that I do not trust but I feel that I need to know what is going on with regards to my medicine, treatment and options. I would go as far as to say that if you have a chronic problem or serious disease you need to be 100% involved in your healthcare.
I just now re-read my thoughts from when I wrote this post. I guess at the time I was in a hurry. I could write for days on this topic. I have been reviewing some applications (apps) on my iphone and I have noticed while we are making great strides in the area of tracking health information we still have a long way to go. I have also noticed that when you Google the subject, electronic health records (EHR),a great deal of products pop up. Some of them new and some of them are old and have been around a long time. I have used the electronic health record from a coder/biller stand point to an auditors viewpoint. I have even used many products from a patient perspective. I have read and studied so many of them as a registered health information technician (RHIT) but I still find them lacking with a very important component. The patient vantage point is still missing. It is a critical link to fixing a broken health care system. I have noticed that for the most part it is still up to the patient to track their health care. Oh sure, the hospitals and now most clinics and doctors office have an electronic health record but it is for them (health care providers. They can track everything from your where you are at in the hospital to your medicine to your urine output but still there is a gap that must be filled. The gap is between the patient and the health care provider. More education needs to continue and the patient needs to speak up and ask more questions. The physician and all health care providers need to learn how to communicate with their patients better. Why do I feel so passionate about this topic because I see it playing out right before my eyes as I go in and out through the health care system.
Here is what I see. This is just an everyday occurrence, medical errors that is. I see the patient entering through the ER and then the health care provider decides to admit the patient because they are very ill. (Ok some serious tracking going on now). The hospital knows where the patient is at all times and inside the electronic record is all of the patients information from the medication they are given, vital signs to what the patient ate or didn’t eat while in the hospital. But information in is information out in a lot of cases. Or like the old saying, “Garbage in is Garbage out.”
Let’s start with a scenario and let’s tale a closer look at where the communication starts. It starts with the patient. The patient comes in through the ER or doctors office and starts by sharing with the physician or hospital staff information about their health. The patient shares information from a financial stand point as well as from a medical stand point. The patient discloses this information so that he/she can seek quality treatment. In this scenario, the patient is asked what are you here for today? A very common question. The patient describes his/her symptoms and shares what medication they are on all the while the clinician is taking notes. They usually document it in their computer or electronic health record (EHR). The patient goes on to tell the provider about their past history and all the surgeries that they have had. Some physicians have you fill out a questionnaire ahead to save time. The fact is that communication can even break down before this point if the receptionist is allowed to write down what you are coming in for and the health care provider doesn’t ask the right questions. Lets say that you describe to the nurse symptoms of a sore throat, sinus headache and drainage running down the back of your throat. The receptionist makes an error and writes, UTI, which is the abbreviation for Urinary Track Infection. Next the patient (you) sees the nurse and he/she takes your vitals and ask why are you being seen and you describe the symptoms and he/she then sends you to the lab for a specimen. The lab asked for you to urinate in a cup. Most patients would do this.
Now lets change the story to what actually happened to me. At his point with cup in hand for the specimen I went back to the nurse and asked why was I asked to urinate in a cup and she told me they needed it since I was coming for symptoms of a urinary track infection. I explained, no I wasn’t that I had symptoms of a sinus infection which is usually abbreviated as URI which stands for an Upper Respiratory Infection. Now, I am not an old person so you cannot blame this on the elderly and I am not an uneducated person so you can not blame it on that. This was clearly an error of communication that started with a receptionist that did not know what he/she was doing or bad hand writing etc. The point is the communication is lacking and errors are being made with or without an electronic health record (EHR) and the patient pays the price, the patients insurance company pays the price and ultimately the patient is the one that suffers.
Medical errors happen every day in America. According to Fierce Health Care Journal, In 2013 it was thought that medical errors leading to death are much higher than previously thought, and may be as high as 400,000 deaths a year, according to a new study in the Journal of Patient Safety. The new study reveals that each year preventable adverse events (PAEs) lead to the death of 210,000-400,000 patients who seek care at a hospital. Those figures would make medical errors the third leading cause of death behind heart disease and cancer, according to Centers for Disease Control and Prevention statistics.