A community of 30,000 US Transcriptionist serving Medical Transcription Industry

Another physician's comments on using the EMR - Can no longer trust physician inputs. sm

Posted: Nov 23, 2012

Below is a link to a NY Times editorial.

"The advent of electronic medical records has been a boon to patient safety and physician efficiency in many ways. But it has also brought with it a slew of “timesaving” tricks that have had some unintended consequences. These tricks make it so easy for doctors to document the results of standard exams and conversations with patients that it appears more and more of them are being documented without ever having happened in the first place."

I look forward to the day when I'll be able to review my medical record on line. It'll be easy in my case since 30 years of paper records with one medical group were lost when the group closed down, but knowing what we know, I don't expect to be pleased.

Physicians have been documenting.... - anon

[ In Reply To ..]
fraudulent diagnoses, procedures that never happened, examinations that never happened, etc for many years, even on the paper documents! This is nothing new. They particularly get reimbursed from Medicare/Medicade for things that never occurred, simply because they "bill" for them! Back in the early 80s, I was doing some ICD-9 coding verification for a local clinic and after working on them for several hours, I verbally made the comment aloud that not ALL of these patients could possibly have the exact same diagnoses and procedures. It was just not possible. I was promptly "terminated" for having stated the obvious. Physicians are no more "godly" or represent a "higher moral standard" than our politicians do. They are as much deceitful as anybody else, just for the almighty dollar! They are among the highest paid "employees" in any nation and yet they have to resort to fraudulent practices in order to gain even more income! It is really no comfort to me at all that 90% of patients view their physicians as next to God, value everything they have to say as gospel, comply with every request the doctor makes of them, when all the while the so-called physician has no interest in their health, only in how deeply he can intrude his hands into the patient's wallet and bank accounts. There may be some out there who truly value the health of a patient, but in this day and age, they are few and far between. I so wish there was an "auditing" system or a "consumer reporter" that would investigate the practices of these physicians and hold them accountable for all their attempted deceit, as well! There is something called the ISO standards and they are so particular about how things are done, right down to the color of ink that is being used on paper documents, how things are worded, and audits are performed randomly, with huge fines being rendered for noncompliance. Some of these physicians need to be scrutinized as well, but since they are deemed so highly in most communities, I highly doubt that would ever come to fruition. JMO.

I agree with you on that. When I worked in house - anonMt

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at a hospital in the 80s doing transcription, there was a very busy OB/GYN there and every...E V E R Y...patient of his delivered by C-section performed for the same pre-op diagnosis. Cannot rememeber what that pre-op dx was, but obviously it was justifiable by the insurance companies. Whether or not he did this for the extra money or so he could schedulize is life, one can only guess, but come on, 30 or so a month 20-year-olds needed C-sections??

Made me angry thinking what he put those young bodies through and how he ruined what should have been a joyous experience for the parents, for the sake of putting himself first. Yet how does one know, we have to trust what they say.

I often wished someone would audit him, pull his oh so obvious records and stop that man. I also wonder if the hospital turned a blind face as they stood to benefit as well.

How about you? Don't mean to be mean, but - you were part of it. BTW, I did lose a

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job in another field (quit in advance of being fired) for turning a well-paid thief in to the state banking commission after management turned a blind eye. Never learned what happened to him as nobody there was allowed to talk to me. Actually, everyone on my level was outraged at my disloyalty to this cool guy (Clarence Thomas's women clerks reminded me of them) and wouldn't talk to me.

We had a choice, we made those choices on our own. - I have no problem with mine.

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I knew they would not listen to me if I opened my mouth, and I knew what would happen to me if I did.

Never expect others to maintain your records - Get copies now

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You do not need to wait for your records to become available online to find out what is there. If you request a copy of your records, the doctor is supposed to provide it. If they have a problem with that, report them to the medical board in your state and find another doctor. They might charge a small amount for the copy-whether they do and how much varies by state.

You should be getting copies regularly so that you have them. That enables you to correct errors in a timely manner and can help you validate the charges to your insurance company so that neither you nor they overpay.

When physician groups close down, they are supposed to make arrangements for the continued care of their patients. That includes appropriate disposition of the records. Active records may be transferred to another office or retired to a conservator. If there is something in those records that you truly do need, try asking your state board of medicine for advice on how to find them.

There is a large hospital ..... - anon

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whose name I will not mention here, but who is very large, has a medical center within the hospital, and who will absolutely NOT release patient records to ANYone, including the patient or another doctor outside "their system." They state that those internal records are "theirs" and they will not release them. All requests go unanswered. It is pretty sad when even another doctor cannot get access to patient records, much less the patient themselves. It just boggles the mind and makes you wonder why they are so "protective" of their records.

Isn't that illegal? The patient owns the right to obtain. Yes, I wonder what - they are protecting, too. Scarry.NM

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.

What!!!???? - missp

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I used to work in the medical records department at our local hospital. The medical files themselves ARE considered hospital property and are NOT to be released. HOWEVER, patients and physicians DO have a right to COPIES of those medical records. Otherwise, how would patients get good continuity of care if they have to transfer to another physician or hospital?

I am not sure about.... - anon

[ In Reply To ..]
how they expect a patient to get good continuing care if they go to another physician. As to the legality of it, I don't know, as the records they will not forward are primarily to their patients who also are covered by "their" insurance policy. The initials of this hospital/clinic/insurance company is KP and they are based primarily in the western states.

This is all changing with the EMR as the various - regulations are rolled out into practice. nm

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x

Kaiser Permanente - a_patient and MT working in medical records

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I believe you are mistaken. I had no problem transferring my records at all when I left California and the Kaiser system. Also, I worked for Kaiser as an MT in-house, in the medical record department, in silicone valley and in Sacramento, and I often noted people requesting their medical records. As a matter of fact, Kaiser will send their patients outside of the system to see specialists when necessary, and they certainly send the medical records with their patients including x-rays. In addition, on more than one occasion, under such circumstances, I transcribed a stat transfer summary as the ambulance or helicopter waited. Also, I OFTEN sent cc's to doctors outside the system when transcribing reports.

yes KP released all of my granddaughter's records - anon

[ In Reply To ..]
She was born with multiple congenital heart anomalies, had 3 surgeries, and when they moved and left KP the KP cardiologist and pediatrician made sure they had all of the records. They facilitated and helped with this.

Anon . . . - Reality View

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Anon, if you believe that, you need more HIPAA training.

What you said there is mistaken. Kaiser-Permanente (the "KP" you mentioned) does provide patients with copies of their medical records. Patients have access to them online, for one thing. For another, they follow the usual release of records procedures.

It is a simple matter to Google "how to get medical records from Kaiser Permanente" and see for yourself. Google "HIPAA and release of medical records" or something along those lines to see the rules hospitals have to follow and that they must provide copies. The only exception is for psychiatric information that may be detrimental to the patient.

If you have been sending letters to them without results, you are not requesting your own records, you are requesting them incorrectly, they can't tell who you are, you have not paid whatever fee is required, or you are requesting psychiatric records which require a special process.

Whatever it is, that organization is not hiding anything and it is not out to get you or anyone else. They are very clear about how you can see and get copies of records. All facilities have to be.

You should know this, too, because all facilities are required to provide patients with a notice of privacy practices. You got one even if you don't remember what you did with it. If you are an MT or work in any capacity in health information, you are supposed to know this.

That should be enough information to terminate the paranoid slant this thread was taking.

An awful lot of assumptions being made here... - anon

[ In Reply To ..]
First off, it is not me trying to get my own records...I live in the midwest, thank you for assuming this and that I know not how to proceed in getting my own records. Secondly, it was not me who mentioned the facilities name....you did. I did not want to expose anything or open myself up to some sort of violation of anonymity here. Thank you for that, as well. Thirdly, I received this information from many, many, many doctors dictations who stated outright that they were not able to get patient records from the facility right in their dictations. It was mentioned also that the patient themselves were not able to get their own records simply because they were the "property" of the facility. These were the facts as stated by the physicians themselves...and of course... we all know they cannot lie, right?? Fourthly, you don't need to be so condescending in your supposed statement of facts even when you don't know all of the facts as stated! My. How knowledgeable you are! And how much better you must feel for denegrading what someone else has to say, by your supposed assumptions! If your nose was any higher in the air, you would drown in a rainstorm.

That is just hearsay - SM

[ In Reply To ..]
Doctors say that patients could not get their records when the patients tell them that. You do not know if the patient even tried.

You clearly stated the organization had the initials KP. It does not really matter who they are because HIPAA rules apply to everyone.

It is unlikely that any organization is preventing patients from accessing their records, regardless of what you hear in dictations. It would be illegal for them to do so.

I thought her response to you was quite - reasoned. NM

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x

Regarding the large hospital that won't release records - Old Pro

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I'll bet a nice piece of paper with "Attorney at Law" on the top might make them have a change of heart, no?

Thanks, "get copies." Our records were conserved, - and the conservator lost them. nm

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