For years when doctors examined a patient they wrote it down with pen on paper. Lab reports were taped into the records, test reports were written, as were nurse's notes, doctor's visits, orders, progress notes, surgical records, and discharge notes. The whole thing held together in a huge metal snap folder called a chart. Doctor's offices and hospitals filed the charts away in filing cabinets when the patient was gone.
The medical-records department run by a notary in each hospital often took up a whole floor. Charts leaving the facility, perhaps to go to court, were accompanied by the notary to swear before the judge that it was the real thing. Then progress. The tape recorder and the Xerox machine. Doctors taped their exams and progress notes and the discs went to secretaries to be typed up and placed in the charts. Nurses and others still wrote out their notes. Slowly in the eighties the more advanced hospitals brought in computers for the nurses and others to log in their entries. Still a printed-out chart, xeroxed and going to court or perhaps to a consult, had to be notarized as authentic.
The problems with this are obvious. If you go to another doctor, he/she does not have access to your hospital records or to the first doctor's records unless he requests them. The transfer can take weeks or even be refused! And if you end up in the emergency department, they have no access to your chart so all tests have to be rerun. And even though the patient paid for the x-rays and tests, they were owned by the entity that preformed them and the patient had no access to them! If the patient ended up in an extended-care facility their chart might be transferred over or not. Patients with chronic conditions could often have that condition overlooked in a new facility. Moving records around was time-consuming and expensive and there was no financial incentive for compliance. Often, however, unscrupulous reporters somehow obtained this information.
On April 14 2001 HIPAA, the Health Insurance Portability and Accountability Act, went into effect regulating access to patient information, dictating that a person's health information remain confidential. Initially it was to protect AIDS patients that were being outed and women who were being fired or shamed for having abortions. Reporting of confidential medical information without consent was made a federal crime. By now the majority of health providers were using electronic charting. Then came the ACA in 2010. It mandated that all health records be electronic by 2014 and paid out $6.5 billion in incentives to doctors and health facilities to switch to the new systems. By making patients' medical information instantly and easily accessible to all who treat them health care became more efficient, less expensive, and vastly improved.
If you end up in an emergency department unconscious from a car accident, if they can find your name, they have your history. They know what your allergies are. They know if you're diabetic, asthmatic, have high blood pressure or a problem with alcohol. If you're addicted to drugs and previously went from doctor to doctor and ED to ED to fake pain to get drugs, that won't work anymore. The laws about who can access and use this information are extensively spelled out.
There are two types of electronic records, EMRs and EHRs. Electronic Medical Records are a digital version of the paper charts in the clinician's office. An EMR contains the medical and treatment history of the patients in one practice. They allow doctors and health practitioners to track data identifying which patients are due for preventive screenings or checkups. They check certain parameters on patients such as blood-pressure readings or lab tests. The computer's calendars remind the office what's due, doing most of the monitoring, insuring that nothing is forgotten. But the information in EMRs need not be on the national database. Only a brief summary of the patient's condition need go into the patient's heath record.
Health means "The condition of being sound in body, mind, or spirit; especially freedom from physical disease or pain; the general condition of the body." Since the ACA is dedicated to keeping us healthy (because it's cheaper on the system when the patients stay well) Electronic Health Records (EHRs) focus on the total health of the patient--going far beyond clinical data collected in any one provider's office. Incorporating a much broader view of a patient's care, it reaches out beyond the health organization that originally collected and compiled the information to other health-care providers, such as laboratories, specialists and technicians. It contains information from every clinician involved in the patient's care.
The information moves with the patient--to the generalists, the specialist, the hospital, the nursing home, the next state or even across the country. They are designed to be accessed by all the people involved in the patient's care. After all, health care is a team effort, and shared information supports that effort. Much of the value derived from the health-care delivery system results from the effective communication of information from one party to another and, ultimately, the ability of multiple parties to engage in interactive communication of information. This is especially true of patients with chronic conditions.
There can be downsides to the EMRs as there are with any electronics. The records can mysteriously disappear into computerland, they can be switched, and they will in time surely be hacked and stolen just as our credit reports and identities are. And nurses and doctors are already complaining bitterly about how much time it takes to "care" for the computer. Some hospitals have diagnostic-tree hardware added to the computers, which gives care directives that irritate health-care givers. But "at the patient's side" clinical expertise trumps the computer any day. Care givers will have to learn when to override the computer and such adjustments take time. Plus, obviously health-care professionals will have to use their muscle to demand that the programs be tweaked to better serve their needs.
Still the benefits far outweigh the risks. The future is here, we have to deal with it! The genii will not go back into the bottle! Best of all, the ACA modified the HIPAA act to state that all electronic records, EMRs and EHRs, must be accessible to the patients! With the ACA's new philosophy of educating the patients about their health and making them a partner in their health care, you are encouraged to get copies of your EHRs to study and understand them.
So if you have been in a hospital since 2012, call them up, ask for the Medical Records department and tell them you want a copy of your chart. Some will send you out a form to fill out. Some merely need a letter with your signature on it and a copy of your ID. Call your doctor's office and tell them you want all your medical records sent to you. They have to get them to you within 30 days. You can get them electronically or printed out. I got a black 3-ringed binder with a box of plastic folder inserts to keep my records in so I can sort through them. My son keeps his on a thumb drive.
Sort out your records, the doctor's exam notes in one section, treatment notes, lab results and medications in another. Tell the Medical Records manager that each time you have a doctor's visit and lab results that you want them sent to you so you stay up to date and can check your records out. Then you can do research on your computer if you want to. The more you know about your health, the better your chances of staying healthy.
In some practices, especially here in California, doctor's offices and clinics have portals, another innovation, taking medicine into a whole new virtual world. The password-protected portal connects your computer to your caregivers.
"It really has transformed face-to-face visits," one doctor states, explaining that portals allow patients and doctors to be on the same page when it comes to patients' medical information. Having information archived electronically allows both patients and doctors to review old information that could be clinically relevant at the present time. It allows you to ask questions like, "Did I have a cold the last time I had an asthma attack? Was that the trigger?"
Used correctly even before you get home from your appointment you will have a summary of what was discussed at your visit and what was recommended. Then you can ask questions that you might have forgotten when you were at the office. According to the American Academy of Family Physicians, 41 percent of family-practice physicians use portals for secure messaging, another 35 percent use them for patient education, and about one-third use them for prescribing medications and scheduling appointments.