Is the main purpose of medical records for doctors to communicate with each other as well as to remind themselves of the details of a patient’s condition or treatment? Who actually “owns” your medical chart? Have you ever read your own medical record, in hospital or in general practice?
Until recently at least, doctors were inclined to be somewhat possessive about their clinical records. There are plenty of good reasons for this: medical confidentiality is a big issue: some doctors password- protect computer records so that only a limited number of health professionals can access clinical detail. Informal reading of your own record has never been a problem; but when data protection or legal requests form the basis of the request, an element of formality and defensiveness may creep in.
There have been proposals in England to offer patients online access to their records, which the department of health there has acknowledged represents “a challenge to the culture and practices of some healthcare organisations and professionals”. Some advocates would like to go further: as the clinical record is about the patient, that confers ownership. They say transferring control of the record to the patient means better informed and more engaged patients, leading to a more mature doctor-patient relationship.
Physicians, however, remain concerned: records could contain information that might alarm or even harm a patient. And, let’s be honest, doctors by necessity often write in a clipped, jargon-filled way – features that could make some records impenetrable or even unintentionally offensive. If you read the common abbreviation SOB in your chart, would you be insulted or would you accept it means shortness of breath?
Probably the best piece of research into this whole area was published in the Annals of Internal Medicine in 2012. It involved an experiment called “OpenNotes” that let more than 13,000 US patients read what their primary care providers wrote about them. In the study, when the note was finalised by the doctor, the patient would be notified by email.
Read Muiris Houston’s full article on The Irish Times.