Tuesday, June 23

Patient Centered Care and Access to our own EMR

Many of you have asked me to share a personal example of what can happen when a patient who is informed, has good insurance but who doesn't have access to their own electronic medical records.

In June of 2008 a woman was seen at an urgent care clinic early one Sunday morning for chest pain and shortness of breath that was increasing following a recent trip to Montana. It seemed similar to a prior episode in which her lung had collapsed and she knew it was urgent but not an emergency. She is a very well informed and pro-active health care consumer so she checked online to find a high quality urgent care center in the area affiliated with a highly ranked hospital that took her insurance and drove the 10 miles to it. (past 2 hospitals and another free standing ER facility that cost more)

The urgent care doctor ran an EKG but lacked an x-ray tech at that time of day and he was concerned about a possible pulmonary embolism and insisted that she go by a medic unit to the local ER affiliate with the urgent care clinic (instead of the trauma center less then a 1/4 away that another hospital chain owned) to "ensure continuity of care". She was given a copy of her EKG to take with her along with a copy of hand written records that clearly noted the shortness of breath, bradycardia and chest pain following the recent trip and the doctor's concerns about a possible pulmonary embolism after her rent flights.

She was seen briefly in the ER, but they told her they had to repeat the EKG less then 30 minutes after the first one as the clinic and hospital (same name) had different computer systems. She didn't feel like she was having a heart attack and that it felt exactly like the last time her lung had collapsed so she requested that only minimal testing be done and they do this in a step wise fashion to rule out anything serious. Both the doctor and the nurse agreed but the the Doctor immediately ordered a full cardiac panel, connected her to a monitor and oxygen and ordered a chest x-ray.

Her labs and x-ray appeared at first to be fine so she was discharged, told she must have pulled a muscle and to take some aspirin and given electronic "discharge instructions" She noticed that it included 3 prescriptions (Percocet 325 mg - 5mg dispense 20, Combivent 90mcg every 4 -6 hours as needed, Zithromax 250 mg, 6 take daily) which the nurse started to explain to her. After a few minutes of confusion it became clear that she was being given another patients RX instructions (the instructions vs the actual RX)

The nurse simply drew a line through the RX portion of the discharge summary and said it was a mistake. (They then faxed the copy of the discharge w/ the drugs listed on it to her primary care provider)

The patient was concerned that perhaps they had gotten her mixed up with another patient and perhaps the labs or x-ray was wrong also. So seh asked for a copy of her clinical record, x-ray results, labs like she could get from her former primary care office. She was told not only that it hadn't been created yet but to "not worry her pretty little head about it" and besides they couldn't give it to her if they had it, she could only get it from medical records not from the ER.

A few hours later the x-ray was re-read by a radiologist who noted a small pneumo-thorax (but much smaller then ones she had in the past so it didn't need treatment) but it matched her symptoms. The ER doc attempted to contact her by phone and he and asked if she had sufficient pain medication to make it through to Monday. (even though she never was given an RX for anything)

The next day her family practice doc called to ask how her bronchitis was doing why was she was on such potent pain killers when she knew the patient refused them in the past. When the patient told her what had actually happened her Physician said she was concerned and would call over and make sure it was corrected but since the faxed copy of the records seemed to indicate otherwise that is what she had to go by and the incorrect records were also now part of her primary care records. These records would in fact follow her throughout the next few months from provider to provider. (Most docs will go by the written document over a patients recall but this was so clearly wrong that most would dismiss it entirely and tests were repeated unnecessarily)

Given the series of errors the patient again requested a copy of her clinical records vs the incorrect and pencil corrected discharge summary so she could take them with her to her own doctor the next day. She had to physcially drive back over to the hopsitla and and pick them up in person at the medical records dept. When she glanced at the she was surprised to see that she was now a "he" and it was full of errors in the history, the P&E, the clinical notes, procedures and discharge. For example: (note any odd phrasing is from the records not a typo)

there is tenderness to palpation of the parasternal region from the naubmrim almost to the xiphod process (but this is following immediately)
Respiratory Chest - Chest is non-tender and patient is without respiratory distress. (the patient was beein seen for chest pain and SOB both at the urgent care and the ER and in the prior sentence it notes the pain) Breath sounds are clear, bilaterally, without wheezing, rales or rhonchi present.

ED Course
The patient was given a duo neb bronchodilator treatment. (this procedure never happened) With this he (she) felt markedly improved, Repeat lung exam (no repeat lung exam) shows no wheezing. (never had wheezing)

Laboratory evaluaation shows a negative infulenze screen a negative strep screen (neither test was done). Electroylyts and CBC are within normal limits. (not sure if he read the patients records or a male with bronchotis)

A chest x-ray is performed and interpreed by myself showing no evidence of pneumonia (chest x-ray was to evaluate pneumothorax not pneumonia)

An IV was established (no IV was used) The patient was given IV normal saline along with Zofran Dilaudid and ketorolac (none of this occured). With this he (SHE) had marked improvment in his (her) symptoms. (came with chest pain and difficulty breathng and left in the same situation).

The patient presents with what appears to be bronchitits. he is sent out on Combivent inhaler in addition to Zithromax and Percocet. He will return here to leave or vomiting fever or increasing symptoms. He is otherwise to follow up with his primary care pyhsican for a recheck in one days time. he understands to return here acutely above-mentioned symptoms. The patient remains hemodynamically stable here. (this is all obviously the wrong patient).

It is clear throughout the record that the "normal exam" template was simply blown in and pre-populated as there are numerous other inconsistencies such as a normal rate and rhythm even though her EKG and monitor showed bradyacardia as low as 38 bpm and set the monitors off so often they had to turn the alarms off. (note: a slow HR is rarely a problem and this wasn)

It took 3 visits to medical records, numerous phone calls, a call to JACHO and finally a visit to speak to the head nurse of the ER to finally get someone to take a look at her records and make a correction. Her chart remained as above except for a small note that now says, "the above ED courses of incorrect. It was dictated on the wrong patient). Oddly enough her bill remained the same despite the different level of care and procedures that the other patient received.

Did anyone other then the patient catch this? no Was anyone hurt? no (although you have to wonder what the adult male with bronchities chart looks like) . Did anyone do something wrong? no (the doctor appears to have dictated into the wrong chart and missed a small pnemo that other doc's later couldn't see either) Were the records full of errors that could have affected her future care? Yes Was the patient concerned about these records following her? yes Would anyone have caught this simple series of errors if the patient hadn't caught the first error and asked to see the entire record?

Join the and ensure that patients have the right to full access of our health care data, to know the source of the data, and the right to share our data with people and health care providers that we chose to.
Today's unveiling of a Declaration of Health Data Rights is an important action, long overdue, that represents a collaborative effort by a group of health care professionals - activists, entrepreneurs, technologists and clinicians - all colleagues we hold in high esteem.

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