There was a time when most people felt they had no right to ask for copies of their medical records — or even sneak a peek at their chart in the doctor’s office or a hospital.
The good news for consumers is that both the philosophy and technology surrounding medical records are rapidly evolving. Today, consumers are strongly encouraged to keep copies of their medical records in order to improve the efficiency and accuracy of their care.
What this means for you is important. You and your primary care doctor are now at the center of the health information hub. You have the power to see your records, review and plan your health care, spot errors in billing and share your records with others if you wish. You also have an obligation to help keep your medical records private.
Understanding different types of records
There are two types of medical record systems that you can participate in, according to information from the U.S. Department of Health and Human Services:
- A personal health record system is a collection of your own health information that you keep — either papers in a box or in a web-enabled device, such as computer or smart phone.
- Electronic medical records (also called electronic health records) are similar to personal health records but are operated by health plans, physician groups or hospital networks to hold the records of all of their patients. Almost all of these systems today have a secure patient portal in which you can set up a password to access your records.
Personal health record system
You decide what information to keep in your personal health record. You can keep track of your doctor visits, hospitalizations, surgeries, screening tests and immunizations. You can maintain a list of what medications you’re taking or have taken in the past. Many people like to maintain a comprehensive family history. And it’s always a good idea to include documents such as living wills or advanced directives in this file. You can find many types of personal health records programs on the web, and many are free.
Keeping your own records will make it much easier when you have a medical emergency and need information at your fingertips. Personal health records aren’t typically connected to an employer, health system or insurer.
Electronic medical records
A growing number of Americans receive care from physician, hospital or health plan networks that have adopted electronic medical record systems. Most of these systems have a patient portal — a way for you to access your records. The advantage of signing up is that you can not only manage all of your personal health records, but also communicate with your health care providers.
All of your doctors, therapists and pharmacists who are part of the network can open your record and see the complete history of your treatment. Thus, electronic medical records are a solution to a major problem in the U.S. health care system: fragmentation of care. Too often, a patient receives treatment from more than one doctor, but the care isn’t coordinated, according to experts with the Office of the National Coordinator for Health Information Technology. Sometimes duplicative tests are ordered and other times care falls through the cracks. When all of your providers share your health information via electronic health records, each has access to accurate and up-to-date information. That enables your providers to make the best possible decisions, particularly in an emergency.
Most electronic medical record systems permit patients to manage their care easier, including:
- Booking, changing or canceling appointments online
- Ordering a prescription refill
- Sending an email to your physician or health care provider
- Accessing test results
- Reviewing or paying your bill
- Setting up automatic reminders to schedule exams or order refills
Most systems also permit a guardian or relative of a patient to access records. This is a helpful and convenient way for relatives who live far away to monitor the care of an elderly or ill relative and to communicate with the patient’s health care team.
Keeping your records private
One of the biggest concerns about the shift to e-medical records is privacy. Federal law protects your health information, and organizations that operate electronic medical record systems have taken great care to secure these records.
If you choose to download your personal health records to a CD, flash drive or mobile app, consider using encrypted and password protected technology, say information technology experts with the U.S. Department of Health and Human Services. If you send personal health information via email, encrypt the message. Federal rules protect and secure your health information when it’s held by health care providers or insurance companies. But if you post any information online yourself, such as on a message board, it is not protected by privacy laws.
U.S. Department of Health and Human Services – http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/righttoaccessmemo.pdf
Centers for Medicare and Medicaid Services – http://www.medicare.gov/manage-your-health/blue-button/medicare-blue-button.html
Office of the National Coordinator for Health Information Technology – www. HealthIT.gov