Patients Play a Vital Role in Improving the Quality of Information in their Medical Records

Federal incentives such as meaningful use and programs like the Blue Button Initiative are increasing patients’ electronic access to their medical records and encouraging greater engagement in their own care. That’s a good thing since medical records can contain errors External Links Disclaimer.  Having a “second pair of eyes” on the medical record can help improve the quality of the information that providers ultimately use to make clinical decisions. Patients, after all, know the most about their health and want to make sure their doctors have the most accurate information about them. 

Results from an ONC-funded pilot project at Geisinger Health System, recently profiled in the Wall Street Journal (WSJ) External Links Disclaimer, demonstrate that patients can be effectively engaged online to improve the quality of the information in their medical record — helping to spot errors such as outdated information and omissions such as medications prescribed by another provider. The pilot study invited patients to provide online feedback, via a patient portal, on the accuracy of their medication list in advance of a visit to their provider.

The results:

  • Patients are eager to provide feedback on their medication list – 30 percent of patient feedback forms were completed and in 89 percent of cases, patients requested changes to their medication record.
  • Patient feedback is accurate and useful – on average, patients had 10.7 medications listed, with 2.4 requested changes. In 68 percent of cases, the pharmacist made changes to the medication list in the electronic health record based on the patient’s feedback.

As health information exchange expands, there is the potential for erroneous information to be perpetuated. There is also greater opportunity for patients to help clean up that data. And they want to help. A 2010 survey by the California Healthcare Foundation External Links Disclaimer found that “making sure information is correct” is the most useful feature of a personal health record.

Yet, most institutions do not proactively solicit feedback from patients about their health records. The Health Insurance Portability and Accountability Act (HIPAA) provides individuals with the right to request an amendment to information in their record but the mechanism for providing feedback is not yet institutionalized in healthcare the way it is in other industries. The report points out that healthcare could learn a lot from other industries like financial institutions and e-commerce about how to develop effective processes for gathering and responding to user feedback.

There is a growing evidence base that supports giving patients greater access to their information as a first step towards engaging them as equal partners in their care. The OpenNotes project External Links Disclaimer found that patients who were given access to their doctors’ notes reported they do better in taking their meds. Findings from the Geisinger pilot further demonstrate the value that patients can provide when they are invited to participate more fully in their care.

We would like to thank the National Opinion Research Center (NORC) project team and the Geisinger Health System for being such great collaborators on the Online Medication Feedback Pilot Study.

Related Resources:     

Webinar: Keeping EHRs Error-Free: The Value of Patient Engagement External Links Disclaimer

Full Report of Findings:  Demonstrating the Effectiveness of Patient Feedback in Improving the Accuracy of Medical Records [PDF – 657 kb]

WSJ Article: “Health-Care Providers Want Patients to Read Medical Records, Spot Errors” External Links Disclaimer


  1. Jay Vance, CMT, CHP says:

    As a member of the Association for Healthcare Documentation Integrity (AHDI), it’s exciting to read of efforts to increase patient engagement in the healthcare documentation process. Our association, representing medical transcriptionists, speech recognition editors, and other health information and documentation professionals, has for a number of years been actively encouraging patients to know what’s in their own medical records. However, as needful as it is for patients to identify errors which may exist in their medical records, even more important is the need for better quality assurance (QA) processes to eliminate errors BEFORE they reach a patient’s paper or electronic chart. For decades, healthcare documentation specialists such as medical transcriptionists and editors have been that “second pair of eyes” referenced above. As we transcribe and edit dictated patient encounter records, we don’t just blithely type whatever we hear. Healthcare documentation specialists are not only experts in the proper use of the language of medicine, we’re also intimately familiar with the multitude of ways healthcare is provided. We know the proper dosages of thousands of different medications, understand how virtually every surgical procedure is performed, and are trained to understand the entire “story” of a patient encounter. And those are just a few of the qualifications of an experienced healthcare documentation specialist. We have long served as the first line of defense against inaccurate clinical documentation by recognizing and alerting providers to gender mismatches, left/right discrepancies, improper medication dosages, and a myriad of other potentially dangerous errors which would find their way into patient charts if not for our vigilance.

    Unfortunately, the ongoing transition to electronic medical record (EMR) systems and provider-generated documentation has often resulted in the elimination of healthcare documentation specialists from the clinical documentation process, and as a result, errors in patient records are becoming more and more common. Studies have clearly shown that provider-generated documentation with no QA review is many times more likely to contain errors than medical records transcribed, edited, or reviewed by a qualified healthcare documentation specialist. And while we wholeheartedly agree with the importance of patients reviewing their own medical records, in all honesty most patients are likely to recognize only the most obvious of errors, while overlooking other equally or possibly even more serious mistakes.

    Closing the barn door after the horse has already escaped is certainly one of our most well-worn cliches, but there’s no denying it applies perfectly to the issue of errors in patient medical records. There is a well-trained cadre of healthcare documentation specialists already in place who can make a huge impact on the quality and accuracy of our medical records. Unfortunately, a misguided emphasis on cutting costs by eliminating healthcare documentation specialists from the clinical documentation process is putting the health and welfare of U.S. citizens in jeopardy. The American public deserves the protection against medical record errors which healthcare documentation professionals can provide.

    Jay Vance, CMT, CHP
    At-Large Director-Elect
    AHDI National Leadership Board

  2. Crystal DeVelis says:

    Unfortunately, most consumers are not proficient enough in “doc-speak” to find the real errors in their record. A subtlety like febrile versus afebrile, or the very real differences between hypotension and hypertension just aren’t on the radar of the average consumer. Bring back the medical transcriptionists, the “second set of eyes” that used to keep these errors from entering the record in the first place. With EMR, every error propagates exponentially and there is no real mechanism for correcting such errors.

  3. Mark Savage says:

    And patients agree! The National Partnership commissioned Harris Poll in 2011 to conduct a nationally representative survey of patients who knew what kind of medical record system–EHR or paper-based–their doctors were using. Of patients whose doctors used EHRs and had online access to their health information, 80 percent used it, including using it to find and correct errors or incomplete information in their medical records. The survey also asked respondents how useful they thought electronic health records are in helping patients make sure the information in their medical record is accurate. The findings: 92 percent thought EHRs were very or somewhat useful in helping patients make sure their health information was accurate, but only 63 percent thought paper-based medical record systems were very or somewhat useful for this purpose.

    The survey report can be found at

  4. Brad J.Kane DDS says:

    Well the Blue Button initiative is something that should of been done long ago. This is very impressive and is going to help everyone beside the medical industry.

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