How Patients Can Use the New Access to Their Medical Records

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How Patients Can Use the New Access to Their Medical Records

By MARY DUENWALD

Published: May 11, 2004

t one time, polite people never asked to look at their own medical records.

To do so would indicate a lack of trust in your physician. Besides, doctors

were so resistant to the practice that getting hold of your records could

require a subpoena.

But that way of thinking is a relic of old-fashioned medicine, as out of

date as the house call and the black medical bag.

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Since last April, federal law has required that doctors, clinics and

hospitals provide patients with access to their records on demand. As it

turns out, many people want to see them, and if you know what you are

looking for, medical records can be easy to decipher. Reading them can also

be a good way to become more involved in your own medical care.

Doctors once suspected that patients who wanted to see their own charts were

distrustful or, worse, planning to sue, said J. s, chairman of

the health law, bioethics and human rights department at Boston University

School of Public Health. And some doctors argued that patients lacked the

expertise to understand their own charts.

" They'd say, you can't possibly understand because it's written in medical

language, " Mr. s said. " You won't know that S.O.B. stands for shortness

of breath. "

But in this era of consumer medicine and increasing safeguards on personal

privacy, Mr. s said, " it is considered a basic privacy principle that if

anybody has personal information about you, you should have access to that

information, too. "

The new federal rules, part of the Health Insurance Portability and

Accountability Act, or Hipaa, give patients the right to inspect and copy

all their records. Parents are also entitled to their children's medical

records.

An exception is made for notes from psychotherapy, which are thought to be

especially sensitive or likely to be misinterpreted as critical of the

patient. With a doctor's permission, patients can view therapy records in

the doctor's presence.

Access to medical records will soon be very easy for anyone with a personal

computer, as hospitals and clinics switch to electronic record-keeping. But

even with paper records, obtaining access is easy. Patients need merely

telephone their doctor's office or a hospital's records office and ask, said

Carol Ann Quinsey, a professional practice manager for the American Health

Information Management Association, a professional organization.

Typically, the office manager or the records administrator will schedule an

appointment for the patient to come in and examine the records. Once there,

the patient may be asked to sign a form authorizing the release of the

records.

Or the patient can send a written request to have the records photocopied

and sent by mail. The doctor's office or hospital may charge a fee for

photocopying and postage.

Ideally, when looking through the file, the patient should be able to ask a

doctor or other informed medical professional questions about anything that

seems confusing or hard to understand.

Deciphering handwriting is another challenge, insurmountable in some cases.

" It isn't just that the patients can't read it, " Mr. s said. " Sometimes,

nobody can. "

What pieces of the record are most interesting and important?

The ones that a patient might need to provide to future physicians, said Dr.

Jinnet B. Fowles, vice president of research for the Park Nicollet

Institute, a health research center in Minneapolis. Those might include the

dates of immunizations and regular screenings like mammograms, P.S.A. tests

and cholesterol checks; the dates of any surgeries and the hospitals where

they were performed; a record of all allergies; accounts of any serious

medical illnesses; and descriptions of current medical problems and

medications.

Dr. Fowles found that reviewing her own records gave her a starkly realistic

view of how her weight had increased over the years and how her blood

pressure and blood sugar numbers had " moved in the wrong direction. " The

revelation inspired her to lose 30 pounds.

Patients may want to photocopy the pertinent pages and save them in a file,

said Ms. Quinsey of the information management association. Or they may want

to transfer the key details to a health history record form. (Her group

offers such a form on its Web site at www.myphr.com/maintaining /index.asp.)

Some patients may want to carry a partial record of their medical profile

with them at all times.

" I'm allergic to penicillin, sulfa and tetracycline, " Ms. Quinsey said. " All

those drugs are essentially deadly to me, so I keep that information on a

piece of paper that stays in my billfold. "

People who suffer from chronic conditions like diabetes or high blood

pressure are advised to keep that information with them also, Ms. Quinsey

said.

It is important to check for inaccuracies: misfiled pages from another

patient's chart, for example, or incorrect notations about allergies or

medications.

Sometimes, Ms. Quinsey said, a patient disagrees with a doctor's description

of a medical situation: " A patient will say, `I didn't say that I'd had five

drinks and crashed my car.' "

If the doctor will not change the chart, patients are entitled to write down

their versions of the events and attach them to the record.

Contrary to patients' expectations, the doctors' notations are typically not

all that interesting, Ms. Quinsey said. " If they think there's gossip in

their chart, they are usually disappointed, " she said. " Most doctors don't

write comments like `She was very short-tempered,' or `She was really nasty

to me.' "

Naturally, the trend toward greater openness with patients has discouraged

doctors from jotting down ill-considered comments. " They are encouraged to

stick to the facts and not characterize patients as `fat' or `shabbily

dressed,' " Mr. s said.

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