We hear so much about healthcare reform and how it will potentially affect us as healthcare consumers. One particular area of concern is the management of a patient’s personal health record. Most of us just do not have the time or energy to attempt to maintain a system to keep all of our health records up to date and ensure they are accurate. With today’s ever changing technology, the majority of physician’s offices and hospitals are now using Electronic Medical Record software programs that make the job of maintaining, storing and updating large amounts of information in a secure environment. The benefits to this are enormous as it can reduce the risk of medical errors, monitor disease processes, and communicate to a variety of healthcare providers as well as insurance carriers exactly what has been diagnosed, and the medical necessity for specific treatments and tests.
Along with healthcare facilities, it is a wise idea for individuals to maintain their own personal health record that they have access to in the privacy of their home, either in an online format, or in hard copies of records that have been obtained from a physician’s office. This may seem like a daunting task, however starting out in just small steps can pay off in the long term if a person finds the need to provide medical documentation for things such as health and life insurance applications. It is also a good idea to keep your personal health records available if you need to change physicians, or have been referred to or are consulting with another physician for a specific medical problem.
Implementing a personal health record (PHR) entails gathering as much information about your past and current health and organizing it in such a way that it can be easily retrievable and reproducible for circumstances that might require its use.
Maintaining a health record is a shared responsibility between the health-care provider and the health-care consumer. If you doubt that, try filling out a health insurance application without recorded health information to refer to. Traditionally patients have relied upon their healthcare providers to know everything about them and to record that information, but in today’s era of change and looming healthcare reform, that approach is rapidly coming to an end. Just as taxpayers are held accountable for knowing and verifying the information they submit or the information that is submitted for them on their tax returns, healthcare consumers are going to be held more accountable for knowing and verifying what is in their medical record. This will be readily apparent if you have health insurance benefits excluded after your policy has gone into effect because of pre-existing conditions which were not recorded in the insurance application questionnaire at the time of filing.
In deciding whether or not to grant you coverage, insurance companies want to know a number of things about your past and current health such as past illnesses, current illnesses, dates of onset of symptoms, surgeries, past and present medications, allergies, immunizations and even some details about the health of family members that might have hereditary conditions that are significant to the person applying for coverage.
You may be able to obtain some of the relevant information from paper records you already have such as copies of superbills from doctor visits, a health diary, prescription receipts, prescription bottle labels or notes you may have taken during actual doctor visits. As you gather this information prior to applying for insurance, it is a good time to organize it for quick and easy reference for any future needs you may have in records to your personal health information.
It is unlikely that you will have all the information you need at your fingertips. It might be necessary to obtain some of the information from your health care provider(s). You have the right to access your health records. You may view or receive copies of your records, or instead request a summary of the information. Ask for an “authorization for the release of information” form. Complete the form and return it to the facility as directed. Most facilities do charge for copies. The fee can only include the cost of copying (including supplies and labor), as well as postage if you request the copy to be mailed. It can take up to 60 days to receive your medical records, so ask when you can expect to receive the information you requested. Do not be surprised if you meet some initial resistance to your request to view or obtain your records. First, as we know most doctors’ offices are overwhelmed and understaffed. More often than not, the person in charge of medical records has dozens of other requests ahead of yours so do not expect them to jump right on it! Another factor is often staff may regard your request as the potential for litigious intent on your part. It is a good idea to be specific in your reasons for your request and why you think having a personal health record would be of benefit to you as well as the healthcare provider. The healthcare provider will require that you sign an authorization form which is HIPAA compliant so that they are protected under federal law as it relates to the releasing of the patient’s personal health information.
Now is a good a time as any to begin organizing your health records. As we move forward in new directions in healthcare information and management, it is the wise consumer who takes an active role in their care and the information surrounding that care.
C. Prince, LPN
