08 Jun Electronic Medical Records: Study Examines Patient-Initiated Amendment Requests
MedicalResearch.com Interview with:
Dr David A Hanauer MD MS
Department of Pediatrics
University of Michigan Medical School
Ann Arbor, MI
MedicalResearch: What are the main findings of the study?
Dr. Hanauer: In this study we analyzed requests made by patients who wanted to make changes to their medical record. The goal was to develop an understanding of what the main reasons were for making a request to change the medical record, and what types of information they wanted changed.
One of the main findings was that about half of all requests were ultimately approved. This suggests that patients reviewing their records can detect errors and have them corrected, which could ultimately lead to a more accurate record for a patient. In essence, giving patients the opportunity to further participate in their care by allowing them to review their record can lead to the identification and correction of errors or omissions.
MedicalResearch: Were any of the findings unexpected?
Dr. Hanauer: We were surprised that so little had been published on this topic before, especially since there have been multiple efforts to increase information transparency and make records more available. What was most surprising, however, was the very small number of people who had requested an amendment request considering the much larger number of patients who had requested a copy of their records. It is also noteworthy that we noticed an increase in requests after we implemented features from a new electronic health record that allowed us to provide information (such as diagnoses and medications) at the end of every ambulatory encounter.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Hanauer: An important finding from our study was that the number of amendment request was relatively small compared to the volume of patients that we see at our health system on a daily basis. Therefore it does not seem to be the case that allowing patients to view the records will necessarily result in an undue burden for physicians who have to then correct the record. Patient should become more aware of their rights to view the record and to feel comfortable to make changes when they feel it is necessary. Physicians should keep in mind that they may make mistakes and that it might be necessary to correct these mistakes at some point. However it is also important to note that there were a subset of cases where the information was true but patient did not want that information there anyway.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Hanauer: I think one thing from our study that is clear is that we need to make the process of how to view one’s record and amend the record more easily accessible to all patients. In future work we would certainly be very interested in having a better understanding of what actually motivated patients to want to review the record and want to go to the effort to make a correction.
We also would like to know how patients react when a record is either amended as requested or, if the amendment is denied, if they understand the reasons for denial and if they accept those reasons–or if they end up losing trust in the health care system.
Citation:
Patient-initiated electronic health record amendment requests
David A Hanauer, Rebecca Preib, Kai Zheng, Sung W Choi
J Am Med Inform Assoc amiajnl-2013-002574Published Online First: 26 May 2014 doi:10.1136/amiajnl-2013-002574
Last Updated on December 21, 2014 by Marie Benz MD FAAD