By: Steven Nissen, MD
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Does it seem like everything is going digital? When it comes to your medical records, a move to an electronic format has been ongoing. As of 2013, 78 percent of office-based doctors were using some form of Electronic Medical Records (EMR), and paper files are on their way out.
As the EMR becomes more commonplace, doctors aren’t the only ones with access to your medical records. You do as well. You are now able to look at medical reports and ask your doctor questions. This offers you many benefits as a patient, but it’s also important to understand some of the limitations of electronic medical records. Here are some things you should know.
Here are five important things to understand about your EMR:
- It often contains medical jargon that you may not understand. Medical records commonly contain medical terminology a doctor uses to keep track of what he or she has thought or done — and not with the patient in mind as a primary audience. The information can also get technical in these records because it is also used for auditing and billing. Be sure to ask your doctor what any unfamiliar terms mean before becoming too concerned.
- It will keep you well informed about your health numbers. Electronic records make important information about your health much more accessible. You can more easily access your blood pressure numbers, weight and blood sugar control (HgA1C). You can also track how these have changed over time.
- It can help you better understand your doctor’s recommendations. Your EMR allows you easy access to the plan your physician has outlined for your care. You can take time to review it carefully and understand it. This only makes you a better partner in your own care.
- It may contain some inaccurate information. Yes, you may find inaccuracies in your medical record. Here’s how it can happen. When doctors and medical staff note your medical or family history, they don’t always fully understand you. One of my patients saw a heart attack noted on his chart, but he told me he never had one. We had misunderstood what he said during the medical history and promptly corrected it in his record. So, it’s important to let your doctor know if anything in your medical record is incorrect. As doctors, we want the most accurate information too.
- It offers a good way to send a message to your doctor in certain circumstances. Do you know the best situations to use your EMR to message your doctor? It’s ideal for asking a simple question or reporting back on how your care is going. This allows your doctor to make tweaks based on this feedback, which are easy enough to communicate through messaging. It also works well to report back to your doctor if you are keeping a blood pressure log or other data. However, if you have a complex question, your symptoms have changed, or you have new concerns, it is best to see your doctor in person. Then, he or she can order necessary tests, ask you questions and evaluate you to give you the best care.
The EMR is a great tool to help you manage your health and to work well with your doctor. Just know what it can do, and what it’s limits are, and you’ll be able to get the most benefit from its growing availability.