Technology is lacking, process may be unclear
by Cheryl Clark, Contributing Writer, MedPage Today, September 14, 2021.
Changing a medical record to correct an error is anything but an easy process.
Under federal HIPAA rules, patients have the right to request that doctors fix errors, but the provider has up to 60 days to respond, and can ask for a 30-day extension.
The provider also can refuse, but must specify the reason in writing.
If the fix moves forward, the doctor can’t alter the original note, but the patient has the right to have an amendment with his or her version of the facts placed in their electronic medical record (EMR).
Most EMR program modules do not let the patient edit or question something in an electronic note, although software entrepreneurs are working on solutions that will enable that feature.
“There’s not a smooth process for doing that in today’s EMRs. They didn’t really build that into the certification criteria,” said Deven McGraw, an attorney and chief regulatory officer for Ciitizen, a consumer health technology startup.
Then there’s the question of who is responsible for actually making the fix and whether there even is a process. The doctor might refer the patient to the office staff or the doctor’s nurse, who might refer the patient to the practice’s health information or medical records office, which may send the patient back to the doctor.
It’s also unclear whether any federal rules require the doctor to post the patient’s requested amendment in the patient’s portal so other providers can see the change. In one case relayed to MedPage Today, a doctor told a patient that he accepted the amendment but did not download it into the portal.
When asked to amend a chart note that incorrectly diagnosed this reporter with osteoporosis, the physician replied that it was inserted only so that Medicare would cover bloodwork for a vitamin D level, for which the patient would otherwise have to pay. “I was trying to save you money,” the physician said.
That’s not just wrong, it’s potentially harmful, said Heather Gantzer, MD, immediate past chair of the American College of Physicians’ Board of Regents.
If the patient came to the ED with acute back pain and compression fracture on a plane x-ray, and the ED team sees osteoporosis in the patient’s history, a treating physician might say, “this happens” in people with osteoporosis, and initially discount any idea of something more serious, Gantzer said.
If the patient’s record didn’t indicate osteoporosis, she said, “maybe you are worked up with an MRI sooner rather than later, to be sure it’s not a tumor.”