Self-censoring the Medical Record
A patient presented to the ER with a benign complaint at 3 am. She was incidentally noted to have moderately elevated blood pressure, and she appeared much more awake and talkative than the usual 3 am patient. She admitted to recent cocaine use but requested that I not mention that fact in the medical record for fear of possible repercussions. She was a HENRY with good insurance and didn't want to jeopardize those things if her secret were somehow discovered.
Since the blood pressure wasn't dangerously high and the drug use was not even tangentially related to her initial presenting complaint, I complied with her request, documenting only that we discussed lifestyle modifications and secondary causes of hypertension, etc.
When electronic medical records become more common and more widely (if not universally) accessible, I suspect there are going to be an increasing number of patients who will be hesitant to tell us embarrassing and potentially career-threatening information about themselves. Perhaps big brother shouldn't have any more information about us than necessary.
With the possibility of a nationalized healthcare system and the subsequent rationing of care and passive culling of the herd that looms on the horizon, even a one-time chart notation of serious drug use might make receiving certain services more difficult when viewed through the eyes of a cold-blooded single-payer bureaucrat charged with distributing scarce resources. If one happens to need a kidney transplant in a decade or so, it might be better to have a clean record.
But when patients don't give us the whole story, it can make our job very difficult.
Since the blood pressure wasn't dangerously high and the drug use was not even tangentially related to her initial presenting complaint, I complied with her request, documenting only that we discussed lifestyle modifications and secondary causes of hypertension, etc.
When electronic medical records become more common and more widely (if not universally) accessible, I suspect there are going to be an increasing number of patients who will be hesitant to tell us embarrassing and potentially career-threatening information about themselves. Perhaps big brother shouldn't have any more information about us than necessary.
With the possibility of a nationalized healthcare system and the subsequent rationing of care and passive culling of the herd that looms on the horizon, even a one-time chart notation of serious drug use might make receiving certain services more difficult when viewed through the eyes of a cold-blooded single-payer bureaucrat charged with distributing scarce resources. If one happens to need a kidney transplant in a decade or so, it might be better to have a clean record.
But when patients don't give us the whole story, it can make our job very difficult.
Labels: defensive medicine, health care crisis, patients
posted by scalpel at 5:23 AM
49 Comments:
I have to grapple with this issue day after dayThese days the medical record is far less a historical documentation of medical events and far more an invoice and legal document for lawyers. I will post more about this in the near future.
Hmmm. Why did she tell you she had done cocaine?
Good heavens, what is it with you people and your boogeymen? "Single Payer!" "Socialism!" Scary!
I know you've been paying better attention than that, but just for the record, I'll go ahead an knock down that straw man: single payer ain't happening. Not even on the table, even as a losing option.
What's more, the logic here is dead backwards -- people *now* are afraid to tell doctors things because health insurance is a valuable and tenuous thing that can be stripped away by a cold-blooded insurance bureaucrat, or the loss of a job. Having health insurance which cannot be taken away and is portable is *less* likely to chill doctor-patient speech, not more likely.
"Hmmm. Why did she tell you she had done cocaine?"
I asked her.
And SF, she might not lose her coverage, but she might be bumped down the waiting list for an LVAD or a transplant someday, assuming we are still able to offer such expensive procedures once we're all living in Obamavilles and eating cabbage soup.
"health insurance is a valuable and tenuous thing that can be stripped away by a cold-blooded insurance bureaucrat"
As opposed to the loving, caring, warm n' fuzzy Federal Government?
No, thanks.
I'm also scared of socialized medicine, and wouldn't vote for Obama even if he offered me a 13 dollar per week tax cut, but the principle of accepting the consequences of your actions are solid conservative principles.
If you don't want to find yourself down on the list of kidney transplant patients, then here's some advice: STOP DOING DRUGS!
The idea that people can do whatever they want and get away with it is a solidly liberal principle, and quite frankly, I'm a little shocked that you would go along with it. You don't have to go tell the cops, but if a patient comes in with a very real health problem (even if it isn't the reason they gave for their visit) and you ignore it, are you really doing them a service?
When they come in with a near-fatal overdose in a month and the attending doc has no history to go by, will you have done her a favor? When she is living on the street thanks to a habit that could have been broken early on with some help will you have done her a favor? When she needs a liver transplant due to the alcoholism that so often accompanies drug use, will you have done her a favor?
I'm not trying to say that you will be responsible for any possible downfall that she may take, but when you seek to cover the sins of another, you are certainly not doing them any favors.
I would be very, very afraid to have anything perjorative on my record, either to have me denied from a single-payer health plan or by an insurance company.
Braden those are excellent points, and that was exactly the sort of conversation I had with myself. In no way did I ignore her problem, I just didn't document it. I took her willingness to admit to it as a cry for help, and I spent a lot of time counseling her about the physical dangers of cocaine use and a couple of techniques she might try to help her to quit. I told her that her admission in passing was actually much more serious than the reason for which she (supposedly) came to the ER. Maybe she really came in seeking help for her drug use, but she declined inpatient treatment (again, because it would look bad on her record).
A casual entry on an electronic record, like a psych admission, sticks around forever, so I thought she was wise to be cautious. I don't mind taking some lumps over my decision because I'm not sure I made the right one, and I'm eager to hear other opinions.
It may not be ultra-relevant to the current visit, but it puts drug related problems in your differential for future visits.
When I'm asking a patient that has a documented history of drug use about drugs, I simply ask as if it's common knowledge so the patient doesn't try to deny it.
"I see you're shaking pretty badly tonight. Have you used any meth or cocaine in the last 24 hours?"
Why would I ask that? Because someone documented it in the chart.
Also, if the patient starts coming back for pain complaints, it puts that into a new perspective if they have been known to abuse hard drugs. Not the smartest idea to prescribe Vikies to someone who recreationally uses cocaine if you can help it.
So I think that if you don't document it, it's to the patient's future detriment. One of the original purposes of HIPAA was basically what you're worried about here---keeping random people, such as employers, out of your medical record and away from private doctor/patient discussions.
One thing you CAN'T do ethically, IMHO, is tell the patient that it won't go in the chart and then put it in the chart anyway; that's simply lying.
One of my doctors died in December and my med recs have been lost by one of my physician's office staff.
I was talking about this with my PCP and then about his using an EMR in his office which he has for years.
He loves it. He was telling me how he is careful about how he documents about the pt.
He said, for instance..if a patient comes in who has been an alcoholic and they've stopped drinking...he will say something like "not drinking now" instead of labeling the patient with something.
I personally have worried about everyone having easy access to med info and say there is an erroneous, yet harmful documentation in the patient's chart. How would the pt know and what could they do about it?
And as Nurse K said...with HIPAA in place...how or why would employers have access to that info? I thought that IS why we have HIPAA...to protect the privacy of a patient. ??
They told us in a class at the hospital... that even a person passing by a patient area who witnesses a HIPAA violation, could report the hospital for said violation and the hospital could be fined.
So..if they are that strict..then why would other non medical parties gain access...barring corruption of some sort?
Hearing this stuff causes me to not want to confide as openly as I have done in the past.
Interesting -something intended to help the patient could actually harm the patient.
Nurse K, you just accidentally revealed why she didn't want that in her record. Because once that's in the record, every future interaction is clouded by that one entry.
Painful condition? Sorry, can't help you. Nervous? Must be the coke, no tranquilizers for you. CHF? Sorry, no transplant, you must have cocaine-related cardiomyopathy. We're going to drug test you for a year before putting you on the list. No matter what you present with, there's going to be someone eager to jump to an early and possibly inaccurate conclusion based upon that one historical feature, and THAT might be detrimental to your health.
And HIPAA will not protect you from that sort of discrimination. You really think nobody reads your chart?
Go ahead and blast me. In a socialized health care system, don't doctors and nurses sometimes strike? Why wait to fight back? I know ... it is unconscionably cruel to patients. But so is the health care system into we are heading. What alternatives exist for pushing back?
I read somewhere where someone suggested that Indian reservations might do a booming business if they were to set up private hospitals and clinics. I wonder if that could work?
So, Scalpel, you don't think the average doctor can't figure out when factoring in drug use is and is not important? Maybe you don't work next to a few major homeless centers, but a good number of my patients have drug problems. They still get the same workup as everyone else if the problem sounds like it needs a workup. We have a few cokeheads that get chest pain workups all the time, but they're just seeking ACLS morphine, so they have orders to only get morphine for acute MI. Not unreasonable given your history of abusing the system in the past.
I'm not a huge fan of using the ER as a "nervousness" center, so big deal if you're "nervous" and don't get "tranquilizers", no matter who you are. Being 'nervous' is not an emergency. I don't subscribe to the idea of giving every cokehead in the neighborhood ativan IV when they have a bad high unless they're violent, then they should get it no matter what the cause. I'm talking more the #15 Vicodin for sketchy back pain.
As for heart transplants, if you're using IV drugs, there's a good chance your cardiomyopathy is related to that, but most cokeheads don't inject. What you seem to be saying is you want to help the patient lie in order to get a transplant that otherwise wouldn't meet criteria for an extremely scare resource, possibly denying the heart to someone who would benefit more from it.
So, you need to put that stuff in the chart. If she doesn't want that stuff in the chart, then don't show up at the ER high on it.
Our electronic charts distinguish between substance abuse and 'episodic drug use' or something like that. Really you have no way of knowing if she is an abuser or someone that just took it once at a party. If you were asking me, I'd tell you to put it in as episodic drug use.
My position is that we don't have to put everything in the chart. She came in for (let's say) a UTI. I didn't even have to ask about the drug use, and she certainly didn't have to tell me the truth about it.
If she'd come in for something more serious or somehow related, I definitely would have charted it like usual. Probably the fact that she had so much more to lose than the typical crackhead was a factor as well. She was a high level executive for a well-known company who probably makes more than I do.
Why risk screwing up someone's life when they have been honest and reasonable with you? I chose to try to help her instead.
Most ER docs would have just written her some bactrim and went back to sleep.
Why the heck did you even ask her? I never ask that sort of thing unless it is relevant to the visit.
Exactly.
Her BP was about 170/100, and her HR was 110. She was wide awake and talkative at 3 am, and there were only a couple of patients in the department, so I had some time to spend.
I don't usually start patients on BP meds or work them up for one elevated reading, but I do suggest eliminating stimulants and limiting salt which gives them something to do until they followup. I actually saw her a couple of months later for something else and her BP was normal.
Uh, dood. Those vitals are abnormal and if you can hazard a plausible guess why (cocaine) given her lack of other underlying pathology, that should be documented, don't you think? HR of 110, for instance, could be a sign of many other things including SIRS/sepsis/kidney infection in your 'sample' case. You said 'stimulants', but 'stimulants' like coffee don't cause BPs like that. Cocaine does, however.
You're not the patient's friend or brother trying to keep mom from grounding her, you're her doctor. You know why those are her vitals, so document that she admitted to cocaine use that night and move on.
Nationwide linked EMRs will bring on black market medicine. "Doc can you treat my discharge and not put it on your computer?" After all, if it's not documented it's not done, right?
Nurse K, do not underestimate what mischief future bureaucrats and hackers will do when able to sort through millions of records in a centralized system. The Feds may be thought of as gift-giving Santa Claus now, but remember "he knows if you've been bad or good..." when more covert rationing hits the table.
"he knows if you've been bad or good..." when more covert rationing hits the table.
SO BE GOOD! This is a simple concept. I don't want to lose the heart transplant that I need to someone who has abused their body just because some doctor decided to play fast and loose with the medical record.
I don't understand this concept of moralizing dishonesty in the name of helping others. There are a few very rare cases where dishonesty may be appropriate, but when we think we are doing others a favor by telling a lie, we are just telling ourselves a lie.
It this lady is concerned about the consequences of cocaine use in her job as a high-level executive, then perhaps she shouldn't do cocaine. This seems so elementary, I can't understand why a good, honest, god-fearing doc doesn't just do the honest thing.
New here, passing through, like what I see, glad I stopped by and now adding my two cents.
Jesus-effin-C, I'm only a lowly psychotherapist (tongue in cheek: in practice for decades) and even I know how to be judicious in my management of medical records. How to "document" is not new, people, and if it is in your Tao, either someone didn't train you "good enough", you didn't catch on (for whatever reason) or you're still new to the game...'cause that's what it is in the end, you know, it is a game and do you know how to play has a lot to do with your overall longevity across many boards.
Jes sayin'.
Ain't no thang. Just politics, as usual.
Psycho Therapist I totally agree with you. Charting is a skill that we develop over time. We learn to play the game, covering our assess and watching our patients backs while they receive good medical care.
I'm sure most of us can weigh the pros and cons in a situation like this and respond with appropriate care.
I don't agree that divulging information puts patients at more risk of coverage failure with socialized coverage. This risk seems greater for private coverage.
OK, let's do a 4 hour sepsis workup with CT scan and urine drug screen for a benign honest patient with a UTI and a minor drug problem. You like long megaworkups, right K? The patient might have that rare subset of hypertensive sepsis, don'tcha know.
Or, I can talk with her for a few minutes, recheck the blood pressure after she's peed and relaxed, and send her out in 30 minutes with a buffed chart and a few thousand dollars less of a bill.
Every now and then I try to do what's best for the patient. I shouldn't have mentioned the transplant issue, because worrying about the possibility of a heart transplant makes as much sense as walking around with a lightning rod on your head just in case you get struck by lightning.
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Speaking as a patient..I would appreciate your efforts Scalpel.
It really bothers me that doctors could potentially hurt their patient with how they document?
But are you guys talking just drug or alcohol use?
What are other things that could hurt a patient in documentation?
And who exactly has access..that could be a potential threat to the patient?
There is the perfect world where HIPAA protects everyone from security breaches..and then I am guessing there is the real world where people find ways to gain access.
How are patients hurt in the process and why?
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The thing that scares me is that sooner or later persistent medical records will end up like credit histories, riddled with errors that are difficult (impossible?) to correct. It's one thing to have occasional drug use documented forever (and I think you did the right thing). It's another to have someone else's drug use documented in your records forever.
The last commenter is right. And what about those people who deal with identity theft when their insurance cards are stolen? That seems like it would be a real mess to clear up!
"How are patients hurt in the process and why?"
Ask Britney Spears and Farrah Fawcett. Or George Clooney.
Here's our old friend Deborah Peel:
"Essentially, all medical records — including the average Joe's — are up for sale to large corporations, research facilities and drug companies, said Dr. Deborah Peel, founder and chairwoman of Patient Privacy Rights, a non-profit advocacy group in Austin, Texas.
By signing a Health Insurance Portability and Accountability Act consent form, she said, you not only are giving your doctor and insurance company access to your medical records, but you may be giving them permission to sell your information, as well."
Don't you think that if Sarah Palin had anything embarrassing in her medical record that we would know about it by now?
Great post. I'll withhold judgement of your decision and tell you that I have experienced first hand how a few lines in a medical record can have unintended repercussions. It makes me think twice every time I mention a patients "drug use" or give a diagnosis of "Anxiety". Just one of the many nebulous decisions we make on a day to day basis.....
If your employer fires you for something that is in your medical record that you didn't authorize them to read, you can sue for big bucks and will win. Makes about as much sense as not documenting drug use in case of the 1 in 1 bajillion chance they'll need a heart transplant for cardiomyopathy in the next couple years (before your visit is so outdated that no one will care to read it).
To me, too, a person who even considers going to the ER while high on coke for something as mundane as a UTI (where even the annoying sx are treatable with a OTC Azo or Uristat), whether an executive or not, must not be doing this 'episodically'. Kind of a warning sign when everyday encounters are peppered with being 'high'.
Even one of my cokehead friends snapped her arm in two basically while high and had the foresight to wait until the next morning to go to the ER.
My brother is an AA player, and most of his 'clients' (people he sponsors) are very functional as well, one is even a MD who is an alcoholic and a drug addict (prescription drugs--shocker). Another is a PhD candidate who uses drugs and alcohol. A third is a business owner who used meth, coke, pills, and alcohol, still managed to make a half million bucks a year. Should all their doctors pussyfoot too? How would that HELP them?
I think a good example is someone who maybe works for a roofing company, falls off the roof, gets injured (an injury that will put him out of work for awhile like a broken leg), goes to the ER, and you figured out he is intoxicated. Maybe not enough to where he is obtunded, but say, like a 0.11. Should you document that he is legally drunk knowing he'll likely get no work comp payments for the injury (or very little) and he will if you do not?
Do you not consider that the company's work comp policy payments will go up considerably? Do you worry that maybe the increase will cause another person to possibly get laid off?
Probably a good idea just to be honest when stuff like this happens rather than be a codependent for problem drug/alcohol users. When you say "but they're an executive" or "maybe he'd have fallen off the roof anyway!", you're making an excuse for them.
Texas is an at-will employment state, anyone can be fired at any time with or without cause. And most on-the-job injuries get drug and alcohol tested as a routine matter by the directive of the company. Anyway, as a physician I don't have a duty to the company or to "other people who might get laid off," I only have a duty to my individual patient.
Scalpel, I agree with you most of the time, and I'm staunchly conservative, but if one of the core principles of conservatism is that government should not be the nanny, then that implies that we, as individual citizens have a moral responsibility to help our fellow citizens.
I don't want government-run healthcare because that is not the place of government, but it is certainly my moral responsibility to help my fellow man out and consider the consequences of my actions beyond the first layer. Yes, you have a responsibility to your patients, but you also have a responsibility to society, or civilization falls apart.
Or, put another way: if everybody had an attitude like yours, then we really would have to have the government stepping in with laws. The reason that we don't need the gubment shoving laws down our throat is because we are all adults able to help look out for each other.
In my ER, like half the people have some guy come with them to do an independent drug test, the others don't and whether you wanted to test for that or not is the same as for any other patient who comes in. We don't "have" to do drug/alcohol testing for the company, which is why the companies send their own guy from the work comp insurance company or whatever with.
Your duty doesn't include lying for the patient. Maybe he's pleading with you to not document that he's legally drunk because he'll never find another job in this economy or he has two children at home. Still, if you don't document it, you're lying and helping him to not face the consequences of his actions and possibly even committing fraud (if you deliberately withhold or alter information that you know will affect a court case, sounds like fraud to me) if it affects the company.
In your original example, by the way, there's a difference between the patient telling you on their own that she'd used cocaine and you playing "gotcha" medicine. You don't have to like test everyone for drugs that you suspect is high on them, but, if she tells you that and it's altered her vitals into the 'abnormal' category, you need to write that down.
Also, there's a whiff of discrimination here too---if you wouldn't write it down for an executive, but would for a middle class or lower-class patient, that's a little shifty on its own. I'm sure you wouldn't think twice if the patient was from the local homeless shelter.
It would only be lying if I stated on the EMR that the patient denied cocaine use. If I don't mention it, it's not lying. You may not like it, but that's the way it is.
I don't always document patients' admissions of adultery either, so sue me.
What you're doing is referred to as a 'lie of omission'. Other examples would be not telling your wife you're cheating on her or "forgetting" to add all that money you made as an independent contractor on your taxes. To truly be a lie of omission, one has to believe that the thing not being disclosed is pertinent to whatever is going on. You don't seem to think that drug use disclosed by a patient when said drug use altered their vital signs is pertinent to anything. I do, so I'm calling it a lie of omission. (Not disclosing adultery would probably not be a lie of omission in most medical contexts).
Another good word to refer to this situation is "dissemble", which basically means characterizing a situation inaccurately on purpose. If you gloss over the admitted drug use by saying 'stimulants' instead, that is "misleading".
Scalpel, hope you don't mind, but I linked your post to my twitter thread.
I actually wrote a long comment here but pulled it before posting.
I'm thinking about it. :)
Thank you for answering my questions Scalpel.
Suffice it to know..I now have trust issues regarding med records. And I do wonder..if you can't trust your physicians with personal info...who ca you trust?
Scalpel makes a very good point, and it is worth re-emphasizing. A physician has a duty TO HIS PATIENT. Notto his company, notto his patient's company, notto society at large, not to the patient's family. When time was, (say, 1900) a doctor was in a tremendous dilemma witnessing his patient (with known syphilis, incurable in the pre-antibiotic era) get married. Patient confidentiality forbade mentioning it. Things have changed a lot, and not entirely for the better. Something is either confidential or it isn't. As the examples that Scalpel has mentioned, the pressure to disclose and make money is high, and the consequences are low. (In 1900, that doc could have lost his ability to practice.
Indeed, as physicians filling out a medical record we are not under oath to tell "the truth, the whole truth, and nothing but the truth." Nurse K.--sure, it's a lie of omission. But it is the duty of the doctor to act as a patient advocate, and keep his mouth shut. She did not come to him for help with a substance abuse problem. Brandon--I agree, people should not use drugs.
But, and it's a big but, if you punish people for being honest with you--and that's what making people "face the consequences of their actions is doing", (Brandon) they won't tell you the truth.
Hell, I don't use drugs, and live a boring life, but even as dull a person as I have stuff I wish to conceal, for dignity and privacy. Nothing illegal, but it could be used to hurt me, and I think that is the norm.
He's not talking about calling the patient's boss and telling him or her about her drug use or telling her spouse, he's talking about documenting it in the CONFIDENTIAL MEDICAL RECORD that is only read by authorized people.
This whole post is based on the assumption that there is some huge govt conspiracy to read charts and disclose private medical info to random people just because you can.
Ergo, it's based on a situation that doesn't exist (false pretense), and includes stuff like favoritism (the HENRY doc'll help out the HENRY patient) with a side of deliberately misleading future readers of the chart to "help the patient out".
What if the patient only told ME she'd used cocaine that night? To follow your logic, I also have a duty to not tell the doctor just in case he--gasp--documents it in the--gasp--confidential medical record. Really, if the doctor shouldn't document admitted drug use, the nurse shouldn't tell the doctor about what drugs the patient admitted to using that night either, and the whole line of communication breaks down.
Same as not disclosing in a chart, in my opinion.
Nurse K brings up a good point - if I'm the nurse on this patient, it doesn't matter what the doc dictates, because it's already on the chart.
And no, William, not to make anyone face the consequences, but to be complete in the medical record.
The general argument of "this may cause problems later" is somewhat akin to the argument that guns are evil because somebody might do harm with one. Medical records in competent hands are great tools for helping to treat patients.
Even if I agree with your narrow-minded assertion that you have no duty to society, you still are not being a patient advocate by complying with their every wish when many times those wishes may ultimately do much harm to the patient.
Honesty. Try it, you'll like it.
Nurses don't have the same relationship with patients that physicians do, that's why patients don't tell you their deepest secrets.
And you can write whatever you want, nobody reads nurses notes anyway, LOL.
Funny. Living in a place with both an EMR and a single payer, people still tell me all about their drug use, alcohol, sexual predilections, terrible eating habits, cigarette smoking, medication misuse...
The only one that ever gets in the way of patient care is alcohol use and liver transplantation. The system is not permitted by physicians to make value judgements on patients.
Bariatric surgery and complications? Funded. Smoking cessation? Funded. Heart transplant for cardiomyopathy? Funded. CABG? Funded.
We evaluate patients, certainly, but for whether they are likely to survive the surgery, not whether they deserve it.
You set up a strawman here, in that you must realise that physicians are the ones who must make the decisions, not some third party. If healthcare is to reform, you have to be willing to take control of it and disallow the bullshit practises you seem to fear on the horizon.
You're comparing access to surgical procedures in Canada to the US? Hilarious.
"in the CONFIDENTIAL MEDICAL RECORD that is only read by authorized people"
I usually agree with Nurse K, but I have to take a small issue with this. Who is "authorized people?" You might be comfortable with the authorized people who are reading your med history today, but I don't believe for a second that isn't subject to change.
Personally, I had a fresh-from-graduation college psychological counselor I was seeing during my parents' divorce write a whole bunch of speculatory Freudian BS in my chart which for the rest of my life will prevent me from having a security clearance, serving in the military, or holding public office. What am I going to do, accuse him of lying? He was a Doc, I'm just a civilian. And of course *I'd* lie, obviously I'm crazy. Catch 22.
God forbid some genius up in DC decides its a good idea for employers to have access to medical records "in case of emergency," or I get Joe the Plumber'ed and someone decides look up my records "for my own good."
Scalpel,
After reading this post and all the commentary about it, I must say that I whole-heartedly agree with you and your decision.
I'm not big on this whole centralized electronic medical record thing.
While I have never been big on conspiracy theory, I can tell you that I have no doubt in my mind that the government and it's various and sundry beauracracies as well as every insurance company in the USA has no problem finding a way around any and all laws concerning personal privacy. They can and will access and use all available private information about a person as they see fit and they will justify it in their own mind just like our ex-POTUS justified violating the constitution in the name of national security.
One more thing I can tell you from many years of personal, hands on experience. There is no such thing as a computer or network system that is completely secure.
The ones setup and used by our government agencies are by far the easiest to get into if a person has an above average understanding of computer and network systems and security. Any good, senior computer science or computer engineering college student has the know how to get into these systems.
I have a Ph.D. and over 20 years of experience in R&D of just such systems and my specialty is computer and network / Internet security.
Electronic records are no safer and no more secure than the old paper files in a locked cabinet inside a locked room.
Computer and network / Internet security programs are pretty much designed to keep the honest people honest. They are no more than a nuisance to a determined person with a better than mediocre knowledge of such system that is willing to break the law for a price.
My 2 cents. Take it or leave it. If a person doesn't believe it, I'm sure that sooner or later that person will find out the hard way that they should have heeded my warning.
Joe
Here's some food for thought....the trend for several years in Health Insurance has been companies moving to self-funded plans. That means for many people, their employer maintains responsibility for paying their medical claims and as payor has rights to certain parts of the medical record. Mention cocaine use and a coder picks it up as the 4th or 5th Dx on the claim? Your employer can see it. Especially if you go into an appeal situation. Heck, when I went in for carpal tunnel surgery I had all kinds of crap listed as diagnoses I never knew I had--someone screwed up and put down MS as a diagnosis for me. Just try ever buying an individual health insurance policy with that diagnosis.
really? Nursing notes are not read in law suits? I think if someone wants information bad enough, they will find it. But, I see your point with just being a medical record, and its application in getting coverage for future procedures. Interesting comment though about how patients don't open up to nurses like they do with doctors. Nurses are with patients way more than doctors, we hear everything, so don't think we don't hear it all, cause we do, and probably more than you.
I'm an ER nurse that has, unfortunately, gone over to the other side. I mean I've become the providee instead of the provider. I have Rheumatoid arthritis and "a nurse's back" and some neuropathy from diabetes. So, I visit the friendly pain management doc every month and get my allotment of pain pills. I try to take them responsibly, cause days spent in the ER in withdrawal is like spending a day in hell. I also have a very strong family history of cardiac problems; mom, dad and brother all have stents. Mom has atypical CP because she's diabetic as well. I have presented ONCE to an ER with Shortness of breath and a 25 lb weight loss in 3 weeks. Because the electronic record said that I was a "chronic pain patient" I was not offered ANYTHING that could be considered "mood altering." I told the ER doc, and I use that term extremely lightly, that I was dehydrated because I had been vomiting and had diarrhea for the last three weeks because I was trying to STOP using the pain pills. I also told her about the cardiac history, weight loss and chronic pain that I'm still living with. I can't take NSAIDS for obvious reasons and tylenol might as well be skittles. FOUR HOURS later she told the nurse to start an IV and a bag of fluids, draw labs and get an EKG. No obvious changes on the EKG and after a couple bags of fluid I felt much much better. Then the labs come back; I have an elevated glucose, duh, and UH-O! my troponin is elevated. THEN she tells the nurse to put me on the monitor and tells me she's going to admit me. By this time my back is screaming at me to get off that cement-like stretcher but they refuse to let me walk to the bathroom, cause I really need to be on the monitor, this after I'd been there for five hours. I told them I was going to get up anyway and that they could put me on a portable, so now I'm labeled "non-compliant." So sometime during this debacle the "doc" notices that I'm taking Cymbalta (for post acute withdrawal syndrome) and Lyrica for the diabetic neuropathy. Her mind goes to work and attaches another lovely label "fibromyalgia." We all know what goes through the mind with this label, just admit it, and move on. Now I'm starting to get a little angry at her because she is just not listening to me. Five hours become eight and after she advises the admitting doc who does not know me to deny me even a benadryl so that I can sleep and allow them to do the obligatory troponins.....that's when I decided that I had had enough and got up and went home. They were really pissed when I turned off the monitor (cause it wouldn't shut up) and told me I'd just wiped away 8 hours worth of BP's or sats and their all important strips to document my HR for the last three hours of my visit. My training indicated to me that BP and strips are to be pulled every 15 for the first hour and then at least every hour and more if they are abnormal. It was really rich when the nurse walks in with a strip of nitropaste and starts to slap it on my chest. I said "uh, have you looked at my BP lately?" We both looked up and the monitor read 90/45. I just looked at her and said that there is no way in hell that I'm going to let you put that paste on me.
By this time I was so angry and actually feeling better enough to do something about it, I just told them, well I guess I shouldn't say it again....
So, lesson learned..I'm all for accurate medical records that can be easily read and are easily accessible. But I want control of the record. I have such a complex medical and family history and I do not abuse my pain meds and I do not drink alcohol or do any kind of street drugs and it's obvious to all of my providers....I don't doctor shop....I don't visit ER's as a habit, but this ONE MD read my medical record, took what I said as I was trying to be honest with her and wrote me off as a med seeker.
HIPPA is a JOKE. I remember when a famous football player got hit in the chest and wound up with chest contusions and a pneumothorax, he shows up a the hospital where I worked and within five minutes we heard about it up on the eighth floor and the next day it was determined that 300 people had looked at his electronic medical record! I doubt that any of these people were fired but per HIPPA they all should have been.
Scalpel: At least you listened to your patient. Right or wrong you took an honest, open-minded look at her and tried your best to help her.
Thanks for sharing your story. Best wishes.
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