In 2009, Congress enacted the American Recovery and Reinvestment Act of which Title XIII is the HITECH Act or Health Information Technology for Economic and Clinical Health Act. That is a mouthful. The goal is to create a nationwide network of electronic health records to enhance healthcare and reduce costs through better communication. Financial penalties will go into effect in 2015 for institutions and physician’s offices not in compliance that receive money from Medicare and Medicaid.
Behind the scenes a whole lot of data entry has been going on in healthcare to make this happen. The upside for the healthcare consumer, is that critical health information can be available 24/7 and much quicker than before. The downside is that years will be spent tweaking, updating, and evaluating these programs to ensure they are meeting the goals set. As a consumer of healthcare, there are things to know about this process and things you can contribute to make sure the electronic medical record works for you.
Each healthcare system has their own electronic record and they do not communicate with each other automatically. If you see a primary care physician with UC Health and go to a cardiologist with TriHealth and see an independent dermatologist, and then are admitted to a hospital in an emergency outside of either of those systems, the data in your medical record is in four different systems. Each system may think it has the correct picture of you and your needs.
The Electronic Medical Record is only as good as the data entry and the person entering the data. Errors can be made with the click of a button. Personal Example: After a visit to an emergency room, I found out that a local medical system has me listed as taking three prescription medications on an ongoing basis. I take none. A dermatologist office I visited ten months ago made a data entry error and did not specify in the record that these medications were to be taken for only 2 weeks. I was unable to get the emergency room to correct the record and the discharge papers told me to continue taking three medications that I do not take. No harm done, I know better. Had I been admitted, a physician would recognize these as 2 week kind of medications and would not have ordered them. A problem could have come up if a new medication was ordered that showed negative interaction with one of the “not taken” meds. A flag in the system would suggest a different medication be taken which might not be as therapeutic. It could then be ordered with a click of the button and no looking into the issue.
Here is an example of the most frequent problems we find with the system. A patient is admitted through the emergency room. The medication record is pulled up and medications are ordered based on what was correct six months ago. There have been changes in the medication by a physician outside of that hospital’s system one month ago. The changed medication may not be related to the current admitting diagnosis. This leads to a medication error called an unintentional med change. It has become quite common since the advent of electronic records.
It is our responsibility as our own health advocates to help the system and ensure our own health and wellbeing. Know your medications, what they are prescribed for, the doses and who prescribed them. Carry an updated list with you all the time, especially if you take multiple medications. Where ever you are seen in the health care continuum, hand over a copy of this list. If you are admitted to the hospital, ask to see the MAR or Medication Administration Record. This is the paper the nurse uses to administer medications as ordered and document them as given. Make sure this matches your list and find out about any changes. Don’t assume that because you have handed over a correct list, that is what will be ordered. Request that your medical record be updated whenever you see errors and request a paper copy of the update.
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