Wednesday, December 12, 2018
There Is A Fantasy That Data In Medical Records Is All Pretty Good. Sadly Not True It Seems.
A day or so ago I posted a blog on the risks associated with errors in the data held in your medical record.
Here is the link:
I had this commentary on a personal experience from an alert observer sent to me a day later.
“A few years ago I attended one of Melbourne's leading tertiary hospitals for a wider excision of a Melanoma which fortunately was diagnosed very early by me and had not had an opportunity to invade or spread. When I was clerked in for the excision I was asked to sign the consent form 'here' which most patients probably would have done, but being a nosy parker I turned it over and asked the nurse "Why am I signing a consent to have my finger amputated?" The melanoma, which had been excised for pathology diagnosis by my GP, was on my flank! Oh, said the nurse, that consent form is for someone else, it must have been put into the wrong record! We fixed that problem.
When I returned 2 weeks later for review the receptionist had difficulty finding my record on the hospital computer system. As it transpired, in the short time that I had been attending the hospital I had been given TWO slightly different surnames and TWO medical (UR) numbers. We fixed that problem.
The discharge procedures then came into play and I was formally discharged back to the care of my GP. For the next 3 weeks I received 3 follow-up letters from the hospital asking me to please attend for post-op review and discharge which I had already done. We fixed that problem.
During my second visit for post-op review with the consultant dermatologist, being a nosy parker, I looked at my hospital A4 record with the consultant and we were both surprised to find that it did not contain the histopathology report which was also not available in my electronic hospital record. We followed up with pathology and obtained a hard copy. We fixed that problem.
On leaving the hospital I was curious to know why I had encountered so many 'issues' with what should have been a relatively simple process - admit, treat, manage, discharge, all the while recording information along the way. Being very familiar with hospitals and with information technology, on the way out of the hospital I wandered down to the basement and asked to speak with the health record librarian or health informatician as she was then called. We had a delightful and informative chat. She took me on a tour of her department and showed me the pile of documents waiting to be imaged into various patient's hospital computer records. I was stunned to see the size of the pile of documents and to learn how far behind (more than 2 weeks) the department was in imaging the documents into the hospital's computer system.
We discussed the problem. In particular we discussed how dangerous the entire system had become with some information being held in the hospital's manual A4 records and some being held on the computer system and no one reliable source of truth to which doctors and other hospital staff could refer. We couldn't fix that problem.”
And that is just one patient’s experience of confusion and near catastrophe!
All I can say is to point out to be very alert and alarmed while in Hospital and triple check everything. As they used to say “it’s dangerous out there!”. And so it is in Hospital!
Posted by Dr David G More MB PhD at Wednesday, December 12, 2018