Breaking Down Patient Requests for EHR, Medical Record Corrections
Fulfilling patient requests for EHR and medical record corrections is a key part of improving patient safety.
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- As healthcare organizations continue to strive for better patient safety, they will have to ensure an adequate process for fulfilling patient requests for EHR and medical record corrections.
EHR and medical record corrections are exactly as they sound—an update of formerly incorrect medical information stored in the electronic record. Healthcare providers can spearhead medical record corrections, but in an age of greater patient data access and patient engagement, organizations also see patients flag inaccuracies and request an update.
Healthcare organizations need to take these requests seriously, as they have consequences for downstream patient safety and outcomes. By understanding the breadth of medical record errors, plus the role patients can play in flagging them, organizations can better steer their processes for reviewing and potentially correcting errors.
How Common Are EHR Errors?
Errors in EHRs aren’t uncommon. In 2020, researchers found that one in five patients found an error in their medical records. EHR design could be one of the culprits, with separate data showing that EHRs miss about a third of the errors the technology is supposed to detect.
To add insult to injury, many of the EHR workarounds clinicians have developed to get past usability issues can perpetuate errors. In 2022, a JAMA Network Open study showed that around half of EHR notes include duplicate information and that incorrect information gets further documented over time.
The most common types of EHR errors include:
- Prescription errors, ranging from incorrect dosage to incorrect allergy information
- Incorrect treatment outcomes
- Missing lab and pathology results
- Incorrect or missing medical history and symptom details
- Incorrect diagnoses
- Missing information from another provider
- Incorrect patient demographics and social determinants of health
- Incorrect copy and paste
All of this has serious implications for patient safety. Clinicians use EHRs to better understand patient health and make medical decisions. When the information stored in those EHRs is incorrect, providers may make decisions that adversely affect patient health. For example, a patient may get a prescription for a medication they are allergic to if the allergy list in the EHR is wrong.
While clinicians and healthcare organizations do bear responsibility for maintaining accurate medical records, the industry is increasingly calling on the patient to play a role. This is both a solution to clinician burnout problems and still-limited EHR interoperability between providers. Patients are experts in their own medical histories, so some healthcare professionals have identified them as key partners in patient safety.
Patient data access enables individuals to look at their health records, flag inaccuracies, and request a correction. From there, providers can examine and correct issues when necessary, which can lead to an overall improvement in patient safety.
Patient Data Access Helps Flag EHR Errors
In order for patients to help flag EHR errors, they must be granted access to their medical records.
That access is mandated via a number of different regulations, from HIPAA to the 21st Century Cures Act. Healthcare professionals must grant patients access to their electronic medical records and clinician notes.
In the 2020 study showing a fifth of patients flagging EHR errors, 40 percent said they perceived the error as serious. Patients flagging errors were most concerned with errors mentioning the word diagnosis, followed by medical history errors, medication or allergy errors, and errors regarding tests, procedures, or results.
A separate study from the patient advocacy group OpenNotes, which pushes for open patient access to clinical notes, found that this process can work. Of the 29 percent of patients in their study who flagged a medical error via patient data access, 85 percent were satisfied with the resolution of that flag. The study did not dig into what each resolution entailed, but it could range from a provider explaining the rationale behind certain documentation or an EHR correction.
Healthcare organizations can’t rely on an “if you build it, they will come” approach to patient data access and EHR correction requests. Some patients are more likely than others to identify an EHR error than others. The 2020 study showed that patients who were female, more educated, sicker, age 45 or older, or already accessing multiple clinical notes were more likely to flag an error.
A separate study found that racial and ethnic minorities are also less likely to report errors in the EHR, with one of the most common barriers being an unwillingness to be perceived as a “troublemaker” or “difficult.” Others said they didn’t know how to report a documentation error in the EHR.
Including patients in overall patient safety efforts, and in particular EHR error reporting, will require strong engagement. Providers should explain to patients their rights to access their own medical data and how they can read their medical records to detect errors. It is also important for provider organizations to clarify the correct channels through which patients can report a medical error in the EHR.
Process for Addressing EHR Data Errors
Just as HIPAA mandates patient data access, it also protects patient rights to request an EHR correction. Under HIPAA, covered entities have 60 days to make an amendment or notify the patient that they have denied the request.
Patients seeking an EHR documentation correction should start by contacting their provider's office to ask about the process for doing so. Most provider offices give patients a form to fill out, or patients may have to write a letter detailing the correction.
Letters should include the patient's name, address, and phone number; the provider's name and address; date of service; a short and specific explanation of what needs to be corrected and why; and a record of where the patient found the mistake.
Patients should keep a copy of their request and try to identify who will be responsible for fixing the mistake. Under HIPAA, those who are legally responsible for a patient (e.g., for a pediatric patient) may make correction requests on that patient’s behalf.
OpenNotes stresses that healthcare providers are not required to make an EHR documentation correction if they do not believe there is an error.
“But changing a record, even in pursuit of clarity or correction, is not easy and is highly dependent on where you practice,” the advocacy group says on its website’s FAQ. “Moreover, changing a note, whether or not at a patient’s request, is at the clinician’s discretion. If you feel the change improves the note, you can document the change as an addendum, or use mechanisms in place at your institution to edit/correct a note.”
Should healthcare providers choose to correct an EHR documentation error, they should not simply delete the original text. Experts state that EHRs should be flagged to indicate that an update or correction has been made and the original document needs to remain accessible. Experts with the State University System of Florida indicate that adding a comment field should be adequate for correcting the EHR.
EHR vendors are also part of the equation, the experts added. In order to make an EHR correction, providers need to be using an EHR that enables such. The technology needs to be able to track documentation changes, add the date of the documentation correction, and direct users to the original copy when viewing the corrected data.
Ideally, once a correction is made—or when one is not made, a clarification is offered to the patient—healthcare organizations will be better positioned to achieve patient safety. By, in part, relying on patient requests for medical record corrections, organizations can bolster stronger patient engagement and achieve better patient activation in care.
