Monday, October 16, 2006

For The Record

Dr. A wants to talk about Electronic Patient Records.
Who can blame him? It's all the rage.

Okay, so psychiatrists don't do Electronic Patient Records, at least none that I know of. I work part-time in a clinic associated with a major hospital center, for every department except psychiatry, notes go into an EPR system. From my point of view, this is terrific, when a patient comes in and says they're on the white pill for their blood pressure, I can access the primary care note and see which little white pill. When they say a lump was found in their you-name-the-body-part, I can look up the radiology reports and see whether this is worrisome or not. Need labs? Maybe they were done last week and don't need to be needlessly repeated, I can look them up!

So what's the down side? Privacy, I suppose, and really I don't think about this from a health care point of view, but from the perspective of being a potential patient/employee of this major medical center. There are safeguards on the system: employees are told never to access the records of those who aren't their patients, we are told that who accesses the info is easily traceable, and the sanctions are considerable, but there isn't a full-proof guarantee that someone who is curious won't access someone else's records.

Somehow, my baseline is to be fairly paranoid about my own medical information. This is an interesting concept given that my existence has generated a minimal amount of medical information, none of it too colorful, and it mostly boils down to I never want anyone anywhere to know what I weigh. Still, some of my patients Google me, and some of my patients have access to the EPR; might a curious patient do the Google equivalent of checking out their own docs in the EPR?-- Just as an aside, how does confidentiality work if a health care worker patient confesses to a psychiatrist that he has illegally accessed the psychiatrist's private medical information? Can the shrink break confidentiality in order to stop the patient from continuing to violate his own confidentiality? Hmm....let's not even go there and I'm sorry if I gave anyone a headache thinking about this.--- And what about my co-workers, my supervisees, and a good number of my friends and neighbors, many of whom can enter the EPR? The bottom line is that I'd have to be pretty sick to seek care where I work.

So no, I've never looked up any one in the EPR out of curiosity; when I see a patient in my private practice who has had care at the hospital, I ask permission to look up their medical information. Invariably, I'm told, "You're my doctor, of course you can look at my records." It seems to me that I need to ask permission, given that they are seeking my help in an isolated setting and wouldn't naturally assume I'd have access to this information. When I see a patient in the clinic, I never ask permission, I often have their medical records printed out in front of me before they even arrive. By getting care at this hospital, a patient implicitly gives consent to have their information entered into the EPR.

.>>>>>>>>>>>>Take My Poll<<<<<<<<<<<<<


Sarebear said...

That's exactly what I'd want my iatrist to do, under the same circumstances. What you do with yours. My answer would be the same, but it's the respect that is very important.

My iatrist is not retiring, but he's closing his private practice, so I've gotta find a new one. I guess this is something else for me to add to my list of questions for potential shrinks. If they are associated with a hospital or clinic, anyway.

NeoNurseChic said...

I have much to say on this, but every time I go to type something, I can't think clearly enough. Having a crap night. But in the end - I'm a patient, employee, and student at the same university - and I have nightmares about some of that! I am glad that they can access the EHR when I go to the ER and things like that because my allergy to things like benadryl is kinda important and kinda obscure. However, our employee health people are insane about some things - as in, I will have to have a note on Wednesday stating that I may return to work on Thursday after my shoulder injury, or they just won't pay me...even if I go to work and WANT to work - they will stop me from working - I never knew an employer to stop someone from working when they wanted, until I took this job! I had to have all these tests through employee health for my needle stick, which means they can look back and see the thousands of other pages of labs in this sytem on me. As they are my employer, I do not think this is appropriate. But, as part of my insurance plan, I am required to go to a hospital in my health system or else I pay a $2000 deductible and then 20% of everything after. I've had hospital stays around $100,000.....that would be $20,000 I'd still have to pay on my own if I went somewhere else. Plus there aren't any other headache centers around... Oh and because I had to have a Hep B titre for my ER job, I will never forget the day when my former neurologist came into my hospital room and shut the door and said to me, "Carrie....Has anyone ever mentioned that you might have hepatitis B?" My eyes widened..."Noooooooooooo.....I do?" In fact, I did not!! He saw the vaccine titre done for my job and thought this was a test saying I was Hep B positive!!! OMG!!! See what happens???

There are asteriks all around my name stating that my information is protected as an employee, but what's to stop the employee health people from looking? I have never looked up someone I know personally in the records. I look up my own information quite a lot because if I have a test or scan, then I want to know what it says before I go to the doctor. I don't like surprises...I was very glad I learned about my avascular necrosis before the doctor broke the news to me because then I had the chance to look it up, freak out, cry, throw things (out of anger that my knee pain wasn't taken seriously for years and resulted in something so awful...), and then get it out of my system before going to see the doctor - and it also gave me the chance to ask very informed questions instead of having the shock of the appointment, then having to leave to look it up, and then coming back to ask the questions.

However, if someone was going off the neuro transcription reports as a way to get my med lists and current info, then they're in trouble. I've never seen such medical inaccuracy. Even though the computer clearly shows 7+ inpatient headache stays, the last transcription report says, "Patient has been hospitalized on 2 other occasions for headache." Wha? At one point, it had my wrong age. Those inaccurate transcription reports are actually the reason I was given a TCA while on an MAOI, even though I hadn't been on the TCA in months. Somebody read that thing, listed pamelor as a current med, and the pharmacy did not catch the pamelor/parnate interaction! The transcription reports also lists "psychosis NOS" as a diagnosis...all because my docs loaded me up with anticholinergics and I had a toxicity reaction - is that fair? Do I want my employers knowing that? It wasn't like I had a natural psychotic break if THEY caused it, is it?

I could go on....but there's no need - it just keeps going on those same lines. And some of the most important things that I would like to say, I cannot say in public....Dr. A probably knows what I'm referring to - since I've told him what meds I'm on for headache - but this is yet one more problem of being a patient, employee, and student at the same place....

If it were just about EHR for me as a patient, then I would be glad that any of my docs could access the info. But it's not. It's also about me as an employee and a student. And that's where I have my own personal concerns. This is hardly even the tip of the iceberg - so obviously I have an awful lot more for people to find out about than just my weight!

Good topic...

Fat Doctor said...

I don't have a private bone in my body, as evidenced by the word diarrhea on my blog, but I respect the hell out of other people's privacy.

Many of my patients work in the hospital or are students at our medical center. I encourage them all to do "spot checks" with the privacy officer to see who has been accessing their chart. Unless it's me, a nurse who checked them in or someone else directly involved in their care, it's a violation and must be reported.

I've never had anybody take me up on that offer. I think they choose to forego a bit of privacy when they choose me to provide their care.

What I hate most about EMR: I spend too much time making the history grammatically correct. Whereas under ROS I used to write a couple of comments like +BRBPR and +SOB, I now spend hours checking little boxes. Click. Click. Click. Our system, at least, encourages us to OVERdocument. It's very time consuming.

Thank you for listening. I have to go finish some charts now.

Sarebear said...

Actually, I find the fact that my family doc uses the word "hirsute" to discribe me so often, rather embarrassing.

*insert monkey sounds here*

When I got ahold of my medical records a couple years ago for my SSDI claim, I read through these; I worked at a health insurance company mostly for the Underwriting department but also as receptionist/secretary in Claims/Customer Service (should be called DISservice . . .) . . . I took a medical terminology class as required for the job.

So, I know much of the medical shorthand and other stuff.

I think a couple of times of hirsute is plenty, except for the annual physical . . . Why note it every other time?

Woops. i go on and on, there.

So. There's my big, hairy secret. hee hee hee! Stupid PCOS.

Off to find my torture device of doom (otherwise known as a hair removal multi-tweezing super fast rotating gold plated multi-discs of electric pain device).

Dr. A said...

Great post and comments. I cross linked you back to my post. Doesn't that make it a vicious post circle? Anyway, I did that because my post is going to be in Grand Rounds today and I wanted to share this post with them as well.

Anonymous said...

zEEK, I really almost answered the last one about chaotic ramblings but you know better. I once again voted with the majority. Pretty funny. It seems somewhat irrelevant given the fact that in this day and age anyone can find out almost anyting they want about an individual if their motivation is high enough and they have access to a computer (although knowing a clever geek makes it alot easier) Love your hair abf

NeoNurseChic said...

Oh on the overdocumentation - no kidding! For one shift, for one's what I do: We have computer documentation where we must sign out every med. If the baby gets blood, there is a paper blood administration record which must be double-documented in the computer. For my unit, assessments aren't online yet, but once they's just one more thing! We have a critical care flow sheet which is essentially 3 pieces of paper conjoined, 2 sides each - I love this is a work of genius - I think this should be all I have to write for my entire shift. If it gets lost, I'm in trouble. It has a comment section, and I keep a running record of everything pertinent from my shift in that comment section. Then I have the chart. I have to fill out the multi-disciplinary plan of care... This is supposed to be a plan of care that is agreed upon by nurses, respiratory, speech therapy, occupational therapy, physical therapy, case management, social work, and last but certainly not least - physicians. Apparently our hospital wasn't getting reimbursed for many cases by medicare due to incompletion of the POC. So now we must check it every shift - but guess who still never looks at it and never signs it? The docs... Medicare pays now though? And then there's the progress notes. You can't just write a general shift note or a general assessment note. Each note must be written in D(ata), A(ction), R(esponse) format. Each note must have one focus - if you have the need to write about neuro, respiratory, FLN (fluid/lytes/nutrition), GI, and social issues, then you must write a separate DAR note for each thing. Sometimes my notes are over a page long for one 8 hour shift.

AHHHHHhhhhhhhhhhhhh I should write a blog rant about this. Because it's just ridiculous. And a lot of it is double documentation. I document my assessment on that critical care flowsheet - and then I write about it again in the note. Oh if we have a baby with neonatal abstinence syndrome, we have a separate flowsheet (now computerized) to score their withdrawal each time we feed them...every 3 or 4 hours.

And this is why I sometimes stay after work for a couple of hours. When it comes down to it, maybe some nurses will do a little less patient care or stocking supplies or talking with the parents, in order to complete that documentation during the shift. But more often than not, I still have to complete my notes after the shift ends, total up my I's and O's (every diaper must be weighed and all bowel movements must be tested for occult blood), and yet still give my report and get out of there. If it comes down to nursing care that I can provide my baby or the family, or writing my notes, well...I always give it to the baby/family every time...and thus end up staying after for unpaid time to finish all the paperwork.

I know everybody in the system has this issue with paperwork, but I just hate it! I do it - and I think because I tend to really write all the details on my notes, it probably takes me longer, but we were taught that our notes must be written in such a way that we would want them to be read in a court of law. So then... Quite the process!!

But from the patient side - I have obtained copies of my own chart from a couple of hospital stays (simply because doctors at Penn State needed it to monitor my anticoagulant therapy) and ER charts. It's interesting to sit and read them - once I went to the ER for severe migraine (I don't go unless it is really bad because I have a headache all the time and I know how people like me are viewed...) - the triage nurse wrote in the note that my pain had resolved by triage, wrote that my pain was a 0/10, but that I was still wearing sunglasses for photosensitivity. This meant I didn't see a doctor for 5 hours. When she saw me, the first thing she said was, "So I hear your pain is better?" Since I hadn't seen the triage note, I had no idea what she was talking about, but I said, "No...who said that? If anything it is now worse than before from sitting in the waiting room" (very noisy, bright lights...). I even had a cluster headache attack for which they got me O2. I was to be seen the next morning by my neurologist for outpatient infusion it was so bad. I don't know why someone would document such a thing...but that really hurt my care until things were straightened out, hours later since I was not seen with any urgency whatsoever. And one of the charts I had to bring to Penn State, it was over 200 pages long, and there were an abnormal amount of pages where I highlighted actual facts that were incorrect: my age, my current job, current meds, and in one case, a med was documented as tried when we never tried it.... It's scary sometimes!

I'm not one who keeps the charts with the intent to sue, just so nobody thinks I'm one of "those" people. Even though some pretty bad things have happened (which I guess is the consequence of having multiple hospitalizations in a huge teaching hospital). I used to get angry - but I don't now. I want it to change - but that's why I am the way I am as a nurse. I don't tolerate any less than 100% from myself as a nurse, and if I can't give that to my babies, then I don't want to do it. I know it probably sounds beyond neurotic - and as a nurse, that's me. As a person, not so much... Just very committed to the cause - because I feel like all I went through has to be worth it. If I can use it to help others, then it was worth it. That's really what drives me. Nutty, I know... :)

Steve & Barb said...

I voted and am in the majority. We use EMR (Cerner) at our hospital. It has its ups and downs.

As for over-documentation... it comes from fear that a payor or regulator will put you in jail from fraud for billing a 99255 (comprehensive inpatient consultation) but that you don't have all 11 (or is it 12) systems mentioned under your ROS, or that your count of 12 mental status elements does not add up to the reviewer's count of 9 elements.
I'd much rather have a POS (piece of software) tell me what code I qualify for after clicking a bunch of boxes. At least, then, you know... none of that lying awake at night wondering if your E&Ms are AOK.

ClinkShrink said... come nobody wants to release their records to me??

I don't mind an EMR as long as they don't put it in a RFID chip and make me wear it in my bicep. I can see it now---walk through a magnetic field and all the sudden your chip says your name is Bruno and that you're a German Shepherd.

Eeesh, maybe I shouldn't give the government ideas.

NeoNurseChic said...

Oh I kept meaning to add this in the comments on Dr. A's post, but I never got around to posting on it.

I actually have an E-Health Key from Medic Alert - the key allows you to put in your medical information, medications, allergies, doctors, emergency contact info and then some - I think you can even save test results to it! I'm not saying this to advertise it. You have to join Medic Alert and then you have to pay for the key.

In all honesty, it is sitting in my drawer right now, and my medic alert subscription has expired. I no longer wear my alert bracelet that tells everybody my allergy to benadryl and to call medic alert for the rest of my info. I'm probably playing with fire, but I got tired of wearing it every day.

The key has the benefit of being able to be inserted into any computer with a USB drive. You just have to have some sort of notepad or reader and it is password protected, but it can be accessed by health care providers, such as in the Emergency Room, or even paramedics - but that's unlikely that they'll have a computer with USB port on the bus. If the key fell into the wrong person's hands, they can't see anything on it. And that's the good thing about Medic Alert in general as compared to the other emergency bracelet companies...(I used to have a different one, so I know) - Medic Alert is 24/7/365. My bracelet had my name, my most important allergy (I have been told that I should have my anaphylaxis to benadryl tattood to my chest my EMS buddies!), the medic alert 800#, and my medic alert ID number. Anybody found me passed out from an allergic reaction, then they would call the number and give them their emergency personnel info - then they could get my info - the emergency room could get a faxed printout even. Very cool...

I don't mean to sound like a walking advertisement for them, but I really found their service to be exceptional. That's for those of us who think walking around with our EHR is important... ;) (Perhaps due to taking 17 meds, or what have you!)