It’s not always easy for patients to speak up and share symptoms in a medical office. And when they do speak up, are providers listening?
Researchers from the University of Michigan Medical School in Ann Arbor have found major disparities between patient self-reported symptoms and the information documented in their electronic medical record. More than one-third of the electronic medical records of eye patients didn’t include the same blurry vision symptoms reported on their Eye Symptom Questionnaire.
Only 23 percent of records reviewed in the study had “exact agreement” between a patient’s survey and their medical record, according to the study published in JAMA Ophthalmology.
“We found pretty noticeable differences between the two,” Dr. Maria Woodward, an assistant professor of ophthalmology and visual sciences at University of Michigan, told Science Daily. “I think certainly the biggest takeaway is when people are presented things in different ways, they tell you different things.”
Woodward said the differences between the records should motivate doctors to re-examine the way they communicate with patients.
“Doctors may be unaware of important symptoms and we, as physicians, should address this disconnect for the benefit of our patients,” Woodward told MedPage Today. “If the EMR lacks relevant symptom information, it has implications for patient care, including communication errors and poor representation of the patient’s reported problem.”
Providers are increasingly putting a greater emphasis on electronic medical records in guiding their examinations and diagnoses. Although the study was limited to a small group of eye patients, health care experts say the findings are significant.
Dr. Christina Y. Weng of Baylor College of Medicine is encouraging doctors and researchers to devote more research to communication errors and accuracy of electronic medical records.
“Although the authors’ findings may have limited generalizability, they draw awareness to the issue of whether EMR documentation is an accurate reflection of the patient,” Dr. Weng wrote in an editorial in JAMA Ophthalmology. “With EMR here to stay, future investigation is needed to provide further insight into these important unknowns.”
Doctors are often over-booked and behind schedule. In rushing to make the next appointment, a doctor may fail to properly document all of patient’s symptoms in their electronic medical record.
That problem is then compounded. The next doctor may rush through a patient’s appointment by saying, “I’ve already reviewed your medical history in the electronic medical record.”
Overworked medical providers don’t receive appropriate compensation for the time it takes to properly document a patient’s symptoms and consult with a patient. We need insurance companies to adjust compensation rates to properly value health care providers for their documentation time.
Until then, patients need to insist that providers slow things down. You should never be rushed through your appointment. You should insist that a provider note your symptoms, questions and concerns. If not, find a new doctor.
Patients also need to persist in disclosing symptoms and concerns at each stage of a medical visit. Yes, it’s in your electronic medical record. You circled it on a patient questionnaire in the waiting room. You told your nurse. And you still need to bring it up with your doctor.
Persist in disclosing symptoms and sharing concerns. Never assume that your doctor knows something about your health.