Do you think all of your Medical Record should be accessible to you?
Or, do doctors reserve the right to withhold any part of your medical record if they think it’s in your best interest?
Let me start this post with a quote-
“A knowledgeable, professional and empathic physician and an honest and sincere patient sharing a well-orchestrated doctor-patient relationship should include full access to whatever documented records that exist between them with full ownership of healthcare data. Any deviation from this will lead to poor clinical outcome and scepticism about sharing any information.”
I remember my residency days when our supervising attending physician, who was MD / JD (Medical Doctor / Juris Doctor), used to tell us:
“While penning notes, keep in mind; you are writing them to your enemies or lawyers and not your friends.”
I agree with him, but it took me this many years to fully realize what he meant. He did not tell them to hide the notes from the patients but wanted them to be clear, legible, and comprehensive enough to be informative and one they can defend in the court of law.
Health information records portray the powerful story of doctor-patient interaction. The value and helpfulness of it will increase if we can make it more detailed and comprehensive, clearing all errors and misunderstandings.
Doctors do not want to Share Medical Records
A survey of 2,300 physicians showed that 2/3 of 66% of them are unwilling to share health data with the patients, while 17% said a strict “no.” The study included Doctors of different specialties in the survey, which may have caused some differences in opinions. For instance, an internist believed that sharing health data would lead to mistrust and deviation from the exception, while a psychiatrist believes in sharing all records.
I firmly believe that any medical record or health data should be the property of the storyteller and story writer. Healthcare involves individual positions and individual patients, and any record should be under their ownership. It should be shared based on contribution and split hundred percent between them. That will increase the trust and remove any bias while strengthening the bond. Poor communication is the grounds for patient dissatisfaction and legal complications.
Whether to Share or Not to Share
Some doctors believe that giving full access to records will give rise to new questions from the patient, but I believe that a physician should review everything in the document with the patient. Some argue; full disclosure of clinical information may be offensive to patients, or, at the very least, patients may not be able to handle its literal nature. However, I assume, any clinical judgment, offensive or not, must be disclosed to the patient.
In my personal opinion withholding, any information from the patient is, indeed, a deviation from medical practice ethics. Some also say that if the patients don’t like the idea, they can go elsewhere- I say a patient has the right to seek a second opinion, but that is highly unlikely if everything is discussed with the patient thoroughly. Others have pointed out that sharing complete medical records would mean patients will research their ailments and compare them with the notes creating compliance issues. In reality, it can only happen if the doctor and patient relationship are not stable.
Patients will always research their problems with or without owning their data. But withholding records can only lead to a premature decision making by the patient simply because, they won’t details of the clinical reasoning that is typically available in their visit notes.
Another, group of physicians made their point as they fear patients may take clinical notes out of context and create poor interpretations of their clinical judgment.
But it is not about translation into layperson terms- it is also about the ability and flexibility to share necessary information without running into hurdles of bureaucracy and a time-consuming, expensive process.
Some believe that it can change the doctor-patient relationship, but I think it would only head towards a positive direction by increasing trust and transparency between patient and physician.
Sharing Data can Work Out for Good
Many physicians are not encouraged to routinely share all medical records with their patients, even though most states legally entitle patients to keep their records.
I remember when I was a medical resident completing my clinical rotations in Bethesda Navy Medical Center and Walter Reeds Army Medical Center, where most patients were in charge of their medical records. There was not a single problem, and I didn’t face any issues with trust or transparency. When such a system can work in military settings, it would also be acceptable in civilian settings.
In the age of advanced digital health technology and big data, corporations and large companies are making billions out of patient information despite serious security breaches.
I say the time has come to transfer the value of health information in the hands of individual people. Many technologies are already laying the grounds that incentivize patients to own their health data and take their health positively, reducing health information piracy and privacy breaches.