As an attorney that limits my practice to Social Security Disability, I am required to review medical records on a daily basis. I normally review hundreds of pages of medical records per day. Kevin Pho, M.D. is an internal medicine primary care physician that practices medicine in Nashua, New Hampshire. He publishes a blog on medical issues and recently published an article titled “Why electronic medical records will not improve patient care or cut costs“. While I agree with the conclusion that electronic medical records need to be improved, I disagree with the title of the article.
Electronic medical records are important because they allow essential information to be communicated in a legible fashion. During an Administrative Law Judge Hearing earlier this week, I had a Judge remark to my client that his mental healthcare provider “needs to learn to write”. Because of the poor quality of these medical records, my client had been denied benefits multiple times. It was impossible for other medical professionals to review these records and understand the degree of my client’s impairment.
Why you should want Electronic Medical Records
- Legibility – records that are typed are easy to read. If your records are not legible, it is impossible to determine the treatment you have received, the complaints that you have experienced, and the objective physical examination results that support your disability. Beyond Social Security, legible records are important if you switch healthcare providers, or if you require emergency care. It would be easy for a wrong diagnosis to be made or to be provided a medication that you have had a bad reaction to if a new physician cannot understand your previous records.
- Redundancy – electronic medical records should be backed-up. Any physician that stores your records electronically should also have a system to archive your records offsite. This is important because if the originals are destroyed, your physician should be able to restore them. If original paper documents are destroyed, the are likely gone forever.
- Access – it should be easier and cheaper to obtain electronic records. Traditional records had to be copied by an individual. Normally the records were bound in a folder and commonly they were hard to feed through a copier. Copying traditional medical records was a time consuming effort. Electronic medical records can usually be printed out with a few clicks of the mouse. Some systems even allow electronic transmission to other doctors, insurance companies, hospitals, and government agencies. This saves your healthcare providers time and should also minimize the cost of record production.
- Quicker Social Security Decisions – if your records are easier to obtain and read, the Social Security Administration is able to issue decisions quicker. In pilot projects where Social Security has been able to obtain medical records electronically, claims have been processed almost 50% quicker (Commissioner Michael Astrue Testimony Before Congress, November 19, 2009). Even your records are not transmitted electronically, your file can be reviewed quicker when the information is provided legibly.
Problems with Electronic Medical Records
I agree that there are currently major problems with the way that electronic medical records are used. It appears that systems that are used and sold to the majority of physicians were not designed with the practice of medicine in mind.
The number one problem that I encounter with electronic medical records is every visit is treated as a full physical examination. Even routine visits for blood pressure checks, common colds, test result reviews, or medication checks, still result in 4 to 8 pages of medical records. Electronic medical records commonly include sections for your complaint, your history, review of your systems, objective examination findings, your diagnosis and your doctor’s plan of care. All of these fields are included on each visit regardless of whether each section was updated (normally only the complaint section and the plan of care is updated).
This method of recording information results in unreliable information. I routinely find that my client’s medical conditions are not described in the review of systems or examination sections when they see a doctor for a routine visit. I have had several clients with spinal fusions where the electronic medical records indicated that a physical examination revealed full range of motion and normal musculoskeletal findings. In the history section, I have seen records that indicated on each of 18 visits over a 2 year period, that my client had started to have leg pain the previous week. Clients have been denied Social Security disability benefits because their treating physician indicated that there were no complaints in areas where an exam was not actually performed.
Improvements Needed for Electronic Medical Records
What is necessary in order to improve electronic medical records, is to only record details that are actually obtained during the visit. The complaint section and the plan should be updated with new information on each visit, the history section and diagnosis sections should be updated, and the review of systems and objective examination information should only be entered if the information was actually obtained during the visit. If an individual’s history or diagnosis changes, the change should be noted with the date of the change and with emphasis added to the new details so that the change is easy to identify. Review of systems and objective examination details should only be included when those details are obtained from a patient, and only the details obtained on that visit should be included.
These changes would help reduce the number of pages of medical records and make the information more reliable. Cutting and pasting should be frowned upon, and prompts should be provided to ask a healthcare provider if the items were reviewed or if exams were completed before the information is inserted into the record. A physician should not be willing for sections to be included in a medical record if the information was not actually obtained on that visit.
What you Should Do
The problems with electronic medical records are important to you because you can be denied disability benefits because of poor documentation. If your physicians do not accurately record your subjective complaints, or indicate that examinations are performed that have not actually occurred, you need to consider switching physicians.
The Social Security Administration requires objective evidence to support your disability, and can deny you if the objective evidence reveals that there is no impairment. Even if one specialist properly documents your condition, if another physician’s records indicate a normal exam, a conflict about the severity of your condition has been created. The Social Security Administration will be required to resolve the conflict and find that one physician is reliable and that the other is not.
I encourage all my clients to be proactive about their treatment. It is important that you know if your physicians are correctly documenting your condition. Ask to review your medical records, and if you cannot read them, it is unlikely anyone else can. If your complaints are not included in your records, it is important to realize that Social Security will be unable to consider them. If there are indications that exams were performed that were not, or normal findings or no complaints are recorded in areas that you experience problems with, it is important to obtain clarification or explanation from your healthcare provider about the conflict. If your condition is not documented well by your treating physician, it is more likely that Social Security will determine that your impairment is not severe, and that your Social Security Disability Claim will be denied.
This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.
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