Computerized Medical Records

I spent countless hours over the last ten years trying to track down the results of a CAT scan I had done. I changed doctors not long after, and when I tried to have my records transferred I was told there was nothing in my dossier to transfer.

It wouldn’t have been a big deal, except at the time I first tried to get the records I was pregnant and couldn’t safely repeat the test. And every time afterwards that it would have been helpful, I was either pregnant or breastfeeding. So no possibility of doing a new test.

Not long ago I went hunting for it again. A new test was being done, and the hospital needed the earlier results to compare it to. I even contacted the archives of the hospital where the test was done, and they claim not to have a dossier for me at all.

How frustrating!

We’ve debated the question of computerized medical records for some time, in my household. It feels a little like Big Brother is taking over when you think that your most intimate details are going to be entrusted to a computer - but then again, we’ve heard all sorts of horror stories about cleaning staff in hospitals sneaking a peak at patient charts. And aren’t there staff in danger of being fired because they snooped into Britney Spears’ chart when they had no business reading it?

Maybe we’d be safer with computerized charts? It would reduce a lot of things we don’t like about doctor and hospital visits: waiting for requisitions and paperwork to be completed, shuffling around to find a patient’s file, the doctor getting the wrong file or missing an important paper from the file…..

A couple years ago my son’s disability paperwork for the government went missing mysteriously. I kept getting notices from the government to say that his dossier was incomplete, but I knew all the papers had been sent to all the right people. I talked to the hospital twice to see if they had sent on the doctor’s section of the claim. Both times I was told in no uncertain terms that the doctor had signed the forms, and she had sent them on weeks before.

I insisted a little harder the second time, and the resident I was talking to went to check for me. First, my son’s file was actually missing. It wasn’t filed, and it wasn’t on the doctor’s desk. I still don’t know where it was located, but the resident finally found it. And when she checked inside, she discovered that the doctor’s forms had been signed and completed but some other papers had been added on top of them. As a result the secretary didn’t see them, and they never got mailed. A month after the date the doctor filled them out, they were finally recovered and taken to the secretary for posting.

I’m thinking, with a computerized chart that sort of thing just couldn’t happen. No, I’m not naive. I know computers can go wonky, data can be lost too. But software that allows doctors to keep an electronic chart is obviously going to have a backup cycle, and this protects charts from any number of things including fires and natural disasters - especially if there is off-site storage for the backup.

Ever been the victim of a medical mistake? There was a story just today about women whose tests had been botched. Some who were the victims of false positives had been subjected, among other things, to unnecessary mastectomies. Some, who I’m going to assume had false negatives, have died and won’t be able to benefit from the review of all the affected dossiers.

I think my worst medical mistake (at least I hope!) was when the OB’s nurse miscounted the weeks of my pregnancy, and the doctor ended up revising my due date because of her mistake. My daughter was born almost two weeks late, which the delivering doctor at the hospital attested to. My OB insisted she was a tad early, despite my asking him to recount & reminding him that the ultrasound had put the due date earlier as well. This is the type of mistake an electronic health chart would minimize.

VirMedice produces what is called practice management software. I’d love to see such a software adopted by doctors, much as all our pharmacists in Quebec now have a program that allows them to keep medication records electronically. All the directions and warnings that we need are quickly made available when the receipts and bottle labels are printed. Imagine having a similar print-out at the doctor’s office, to remind of upcoming appointments or to explain a condition or procedure and help the patient to review the options outlined by the doctor. Or perhaps reminders for the doctor or the hospital nurse, on their computer! Having worked in a hospital myself, I know sometimes things get hectic and it’s easy to forget that a patient has a medication at an unusual time, or that someone has requested assistance for a bath or transfer to bed at a specified hour. Notepads are great for such things - but unfortunately they don’t jump out of our pockets to remind us that now is the time to read them!

I’m sure there are a good many more reasons for us to be looking into electronic health records, and not just those of us who work in health care. As patients, this is a decision that we should have some say in as well. It wouldn’t hurt us to look into the possibilities, so we can offer an informed opinion when the question comes up. Computers are already very much a part of health care in so many other areas. Surely our records will become electronic sooner or later, so we might as well learn a little something about the different options and help guide the decisions of our doctors and hospitals if we can.