Reading the records

by TheEditor

Categories: Investigative, Medicine

The delivery of healthcare is complex business. ¬†Often times records are compiled by large numbers of people in teams or extension of teams about a single patient. The vast majority of Electronic Health Records (EHRs) are text-based. Understanding a patient’s condition(s) and needs from records is often demanding of time, effort and concentration.

Overall, both the delivery of healthcare and the management of health records are complex tasks, necessitating a systematic approach, efficient communication, and the use of advanced tools and technology to manage this complexity effectively. [AC_PRO id=913]

Medical records play a crucial role in delivering safe, effective, and high-quality healthcare. They provide a detailed history of a patient’s health, medical conditions, treatments, and medical encounters, which are pivotal in making informed clinical decisions.

  1. Patient safety: An accurate and complete medical record is essential for patient safety. For instance, it could highlight allergy information or previous adverse reactions to specific medications, which could prevent harmful medical errors. If a doctor fails to thoroughly review a patient’s medical history, they risk prescribing a medication or treatment that may harm the patient.
  2. Continuity of care: Medical records ensure continuity of care when patients change providers or are treated by multiple specialists. A comprehensive understanding of a patient’s medical history allows new healthcare providers to make accurate assessments and avoid duplicating tests or procedures, saving both time and resources.
  3. Legal and ethical obligations: It is both an ethical and legal obligation for doctors to review a patient’s medical records. These documents serve as a legal record of the care provided, and failing to review them can lead to medical malpractice cases. From an ethical standpoint, thorough review of medical records is part of providing patient-centred care, respecting the autonomy of the patient, and ensuring beneficence and non-maleficence.
  4. Decision-making and treatment planning: A comprehensive review of medical records can and should guide decision-making and treatment planning. It can provide insights into what treatments have worked in the past, which can be particularly important for patients with chronic or complex conditions.

Problems

Failure to study EHRs carefully can lead to the following:

  1. Misdiagnosis: A physician may misinterpret a patient’s symptoms and arrive at an incorrect diagnosis if they’re not aware of the patient’s full medical history, potentially leading to inappropriate treatment. For example, they might attribute symptoms of a serious condition to a less severe illness.
  2. Medication errors: A doctor might prescribe a medication that could cause an adverse reaction if they’re unaware of a patient’s allergies or current medications. Some drugs interact with each other, which can lead to dangerous side effects or reduce the effectiveness of the treatments.
  3. Duplication of tests or treatments: Without a comprehensive understanding of a patient’s past medical encounters, a doctor might order unnecessary tests or treatments that have already been performed, wasting resources and potentially putting the patient through unnecessary distress.
  4. Missed preventive measures: A doctor who doesn’t fully review a patient’s medical history may miss key preventive measures, such as routine cancer screenings or immunisations, that could be critical for the patient’s long-term health.
  5. Lack of continuity in care: Particularly for patients with chronic conditions, continuity of care is important for managing their health. If a doctor doesn’t thoroughly review a patient’s records, they may not fully understand the patient’s condition and the steps taken to manage it so far, disrupting this continuity.
  6. Potential legal consequences: In the event of adverse outcomes, if it is found that the doctor did not thoroughly study the patient’s records, this could lead to legal implications, malpractice suits, and damage to the doctor’s professional reputation. In the worst cases doctors can be struck off the medical register at the General Medical Council. In even worse scenarios doctors whose negligence are found to be ‘criminal’ could face gross negligence manslaughter charges and subsequent imprisonment. In some cases healthcare provider organisations can be sued for damages.
  7. Decreased patient trust: If patients perceive that their doctor is not familiar with their medical history, they may feel unheard or unimportant, leading to decreased trust in their healthcare provider. This can result in poorer health outcomes, as the patient may be less likely to follow medical advice or continue with follow-up care.
  8. Complications with comorbidities: Patients often have more than one health condition (comorbidities) which can influence each other and require careful management. Missing this information can lead to complications and sub-optimal treatment plans.
  9. Poor risk management and control:
    1. Inadequate medical history: Past medical history can inform a lot about a patient’s risk for certain diseases. For instance, a patient with a history of heart disease or stroke is at higher risk for future cardiovascular events. Without this information, the doctor may underestimate the patient’s risk.
    2. Missed family history: Family medical history, which should be part of the medical records, can provide valuable information about the risk of hereditary diseases, such as certain types of cancer or heart disease. If this information is overlooked, significant risks could be missed.
    3. Incomplete medication history: Without a full understanding of a patient’s medication history, doctors might miss potential risks related to drug interactions or long-term use of certain medications. For example, prolonged use of corticosteroids can lead to osteoporosis, and certain combinations of drugs can increase the risk of kidney damage.
    4. Lack of context for patient behaviour: Medical records often contain information about a patient’s lifestyle behaviours, such as smoking, alcohol consumption, diet, and exercise habits, which can significantly impact their risk for many diseases. If a doctor does not adequately review this information, they may not fully understand the patient’s risk profile. In mental health services understanding various risk categories is absolutely necessary for sound care. The starting points are ‘risk to self‘ or ‘risk to others‘. However, there are other categories of risk, such as ‘risk of neglect‘, ‘risk from others‘, ‘risk to mental health‘, ‘risk of accidental harm‘.
    5. Missed allergies or adverse reactions: Allergies and previous adverse reactions to treatments are critical for assessing risk. Not noting these can lead to severe reactions, which can be life-threatening in some cases.

    Risk assessment and management are integral parts of medical practice. Adequate review of medical records is essential for these tasks, highlighting yet another reason why it is crucial for healthcare providers to take the time to thoroughly review their patients’ histories.

To avoid these issues, it is essential for doctors to take the time to study their patients’ medical records thoroughly and for healthcare systems to support physicians in managing their workload effectively. But many doctors know about the above, yet they do not study the records carefully. What could account for that?

Records avoidance

Several factors can contribute to doctors not reviewing patient records properly:

  1. Workload and time pressure: Physicians often have to manage heavy workloads and see many patients each day. This leaves them with little time to review each patient’s records thoroughly.
  2. Burnout: High levels of stress and emotional exhaustion, often referred to as physician burnout, can decrease a doctor’s capacity to pay attention to detail and reduce their overall performance.
  3. Complexity and length of medical records: Some patients, particularly those with long-term or multiple health conditions, may have complex and lengthy medical records. Reviewing such records thoroughly can be a time-consuming task.
  4. Fragmented records: Sometimes, a patient’s medical history may be spread across multiple systems or facilities, making it difficult for a doctor to compile a comprehensive picture of the patient’s health history.
  5. Poorly organised records: If records are not well organised, important details can be overlooked. Electronic Health Records (EHRs) can mitigate this problem but can also create new issues if they’re not user-friendly or if the doctor hasn’t been adequately trained on how to use the system.
  6. EHR system limitations: While EHRs have many benefits, they also have limitations, including system performance issues, lack of interoperability between different EHRs, and difficulties in extracting useful clinical data.
  7. Lack of standardisation: Lack of standardisation in how medical histories are recorded can make it challenging for physicians to find the information they need quickly and accurately.
  8. Insufficient training: Doctors may not have received adequate training on the importance of thoroughly reviewing medical records and how to do it effectively.
  9. Human error or negligence: Doctors are human and can make mistakes. Sometimes, they may overlook critical information in a patient’s medical history due to distraction, fatigue, or simply an oversight.

Addressing these issues requires systemic changes, including but not limited to, workload management, healthcare worker well-being initiatives, improved EHR systems, and enhanced education and training.

Complexity of healthcare

The delivery of healthcare is inherently complex due to a variety of factors:

  1. Multidisciplinary teams: Patient care often involves a team of healthcare professionals, including doctors, nurses, pharmacists, social workers, and other specialists. Each of these individuals brings their own perspective, expertise, and understanding of the patient’s condition, adding to the complexity.
  2. Multiple care settings: Patients often receive care across multiple settings – primary care, specialist clinics, hospitals, rehabilitation centres, and at home. Each of these settings generates its own records and documentation, creating a diverse and fragmented set of data about a single patient.
  3. Variability of patients: Each patient is unique, with different health conditions, histories, genetics, lifestyles, and responses to treatments. This individual variability adds complexity to both treatment decisions and understanding of a patient’s health history.
  4. Evolving medical knowledge: Medical knowledge and guidelines are continually evolving, adding a layer of complexity as healthcare professionals need to keep up with the latest best practices and treatment options.
  5. Socioeconomic and cultural factors: These play a significant role in health outcomes and must be taken into account when providing care. These can be complex and require careful consideration and navigation.
  6. Regulatory and administrative requirements: These can add additional layers of complexity, as healthcare providers need to adhere to various regulations related to patient privacy, treatment approvals, billing, and more.

Translating this complexity into records creates an equally complex set of documents. Each healthcare professional involved in a patient’s care may contribute to the patient’s record, adding their own observations, treatment decisions, and care provided. Furthermore, given that most EHRs are text-based, the information is often unstructured, making it difficult to quickly extract key insights.

Also, medical language is inherently complex and often filled with jargon, abbreviations, and acronyms. This further complicates the task of understanding a patient’s medical history and can lead to misunderstanding or misinterpretation of the information.

Moreover, despite standardisation efforts, there can be variability in how different healthcare providers document their encounters with patients, leading to inconsistency in the records. Also, important information may be buried within a large amount of less relevant information, making it difficult for physicians to find and focus on key aspects of a patient’s history.

Advantages of not reading records

Now this might seem strange. I cannot imagine any sound advantages to delivery of healthcare of not reading health records properly.

In general, not thoroughly reviewing a patient’s medical records is considered poor medical practice and is usually associated with more disadvantages than advantages due to the potential for missed information and compromised patient care. However, one could argue there might be a few situational or indirect “advantages,” though these are generally outweighed by the risks.

  1. Time Savings: With high patient loads and tight schedules, doctors might save time in the short term by not fully reading through extensive medical records. This could allow them to see more patients in a day, but at the risk of providing potentially sub-optimal care.
  2. Fresh Perspective: In some cases, not having a detailed understanding of a patient’s past medical history may allow a doctor to approach the patient’s current symptoms with a fresh perspective, free of bias based on past diagnoses or treatments. This could potentially lead to new insights, especially for complex, undiagnosed conditions. But, it should be balanced with comprehensive knowledge of the patient’s history to ensure safety and accuracy.
  3. Prioritising Patient Interaction: Instead of spending extensive time reviewing detailed medical records, doctors might choose to prioritise direct interaction and dialogue with their patients. This can improve the doctor-patient relationship and give doctors a better sense of their patients’ current concerns and symptoms. However, this should be complemented with a review of the medical history to provide holistic care.

These potential advantages should be viewed with caution, as they in no way justify the disregard for thorough review of medical records. Ultimately, while managing time and fostering patient relationships are important, ensuring patient safety and providing the highest quality care should always be the primary focus, and that requires a complete understanding of a patient’s medical history.

Artificial intelligence

Artificial Intelligence (AI) has immense potential to revolutionise the usage of Electronic Health Records (EHRs) in healthcare. AI software is here but not yet readily available or widely integrated into EHRs. This does not mean that doctors should be cutting and pasting information into ChatGPT.

Here are some specific ways AI can be applied:

  1. Natural Language Processing (NLP): NLP can be used to interpret and organise unstructured text data in EHRs, extracting important information such as diagnosis, symptoms, medications, and lab results. This can help in summarising patient records and presenting the information in an easy-to-understand format.
  2. Predictive Analytics: By analysing patterns and trends in EHR data, AI can help predict patient outcomes, identify at-risk populations, and recommend preventative measures. This can enhance decision-making and improve patient care.
  3. Clinical Decision Support: AI can assist physicians in making clinical decisions by providing evidence-based treatment recommendations tailored to individual patient’s conditions and histories.
  4. Automated Coding and Billing: AI can streamline the coding and billing process by automatically assigning the appropriate medical codes based on the information in the EHR. This can improve efficiency and reduce errors.
  5. Patient Monitoring: AI can analyse data from wearable devices and remote monitoring tools integrated with EHRs to detect anomalies, triggering alerts for healthcare providers if necessary.
  6. Interoperability: AI can help improve the interoperability of different EHR systems by standardising and cleaning data, making it easier to share information across different platforms and healthcare providers.
  7. Patient Data Security: AI can also enhance the security of EHRs by detecting unusual patterns of access or potential data breaches.
  8. Population Health Management: AI can analyse EHR data at the population level to track health trends, monitor the spread of diseases, and inform public health initiatives.

In implementing these AI applications, it is important to consider ethical aspects such as patient privacy, data security, transparency, and the potential for biases in AI algorithms. Also, AI should be seen as a tool to support, rather than replace, human judgement and expertise. Healthcare providers should receive adequate training on how to use these AI tools and interpret their outputs.

Concluding remarks

Many doctors may be under immense pressure due to high workloads and burnout, which could lead to a hurried review of medical records. Some may be negligent or simply cut corners due to a lack of time management skills or the complexity of certain records. However, it is crucial to remember that the doctor’s role is to provide the best care possible to their patients, and a thorough review of medical records is integral to that.

There is need for improved training and education around the importance of medical records, as well as the development of efficient systems and processes to manage and review them. The use of technology, like electronic health records (EHRs) and artificial intelligence (AI), could potentially help streamline this process and support doctors in reviewing medical histories in a more effective and timely manner.

Lastly, the healthcare systems should  take responsibility for mitigating issues like doctor burnout, potentially through measures like better workload management, provision of adequate resources, and emphasis on work-life balance, to ensure doctors have the mental and physical capacity to provide the best care for their patients.

Take away summary

  1. Importance of medical records: Medical records play a crucial role in patient safety, continuity of care, legal and ethical obligations, and decision-making and treatment planning. They provide essential insights into the patient’s medical history and treatment responses, which is why doctors are advised to study them thoroughly.
  2. Consequences of inadequate review: Failing to review medical records thoroughly can lead to misdiagnosis, medication errors, unnecessary duplication of tests, missed preventive measures, lack of continuity in care, potential legal consequences, decreased patient trust, and complications with comorbidities.
  3. Factors leading to insufficient review: Heavy workloads, time pressures, burnout, complexity and length of medical records, fragmented records, poorly organised records, limitations of EHR systems, lack of standardisation, insufficient training, and human error can all contribute to doctors not reviewing medical records properly.
  4. Complexity of healthcare delivery and records: Healthcare is inherently complex due to multidisciplinary teams, multiple care settings, patient variability, evolving medical knowledge, socioeconomic and cultural factors, and regulatory and administrative requirements. This complexity extends to medical records, which are often text-based, unstructured, filled with medical jargon, inconsistent, and can contain large amounts of less relevant information.
  5. No true advantages: There are no true, reliable or advisable advantages to not reading medical records properly.
  6. Systemic changes needed: Addressing these issues requires systemic changes, including workload management, healthcare worker well-being initiatives, improved EHR systems, enhanced education and training, and the use of advanced tools and technology to manage the complexity effectively.
  7. Artificial intelligence: Having broken on the horizon, AI software stands to create significant advantages to extracting key information for health professionals to focus on. In this way information overload is managed, and time/effort saved. The ability of AI to assist naturally depends on the quality of such software and how well it is used.

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