ON THE RECORD: Health-care consumers should know what's in their medical files

By Beth D'Addono
FOR THE STAR-LEDGER

Every time you see a doctor, have a medical test, visit an emergency room or are admitted into the hospital, you generate a paper trail.

This trail holds critical information about you and your health needs, both now and in the future.

So you know what is in your medical records?

As and informed consumer of health care, you should. Knowledge of the basic contents of your records an influence more than your own sense of empowerment. Your records can affect your ability to qualify for health and life insurance, affect future employment opportunities and even influence how you are treated by a doctor.

Your medical records tell a story, the documented accumulation of physical exams, test results, doctor's comments and diagnostic information resulting from regular check-ups, emergency room visits and hospital admissions.

The reasons you might need these records are many. Perhaps you are moving to another city, or you are changing primary care doctors. If you have a preexisting condition and are applying for new or expanded health insurance coverage, you might be asked to document past treatment, information clearly spelled out in your record.

When coping with a long-term illness or a rare diagnosis, it is helpful to have a record of treatment and doctors seen - a record which not only promotes better health care, but documents any problems in treatment or medications. If you have an ongoing health problem, such as chronic fatigue syndrome or back pain, you may need to document the diagnosis and treatment for your employer or worker's compensation.

Or. If you feel you have been discriminated against or unfairly treated on the job, your medical records may play a role in a discrimination suit against any employer. You know what's in you credit report, why not have the same knowledge of what is in a much more personal file - your medical records.

Your legal rights

While patients have the right to see their files in every state, New Jersey is one of 16 states that have laws guaranteeing such access to medical records. The procedure is spelled out clearly by law, according to John Washlick, an attorney who directs the health law practice for Morgan, Lewis & Bockius, a Princeton and Philadelphia law firm.

"In New Jersey, as in other states, the actual physical record is owned by the doctor's practice or institution where it was generated. The patient has the right to access and amend or correct any information in those records," he said.

But it's not quite as simple as calling and requesting a file, said Stacy Gansfuss, director of health records services for Overlook Hospital in Summit. "We need to have an original, signed authorization to release records, signed by either the patients or their legal agents or guardians," said Gansfuss, a past president for the New Jersey chapter of the American Health Information Management Association.

Once the authorization is presented (it's best to mail your request by certified mail or hand-deliver it), the health-care organization or doctor's office has a 30-day window in which to produce the record. If you do not receive your records within those 30 days, and think you need an advocate, you can contact the state Board of Medical Examiners or the American Medical Association for assistance.

"We see an average of 30,000 cases a year, plus 25,000 ER visits," said Gansfuss. "Multiply that by years, and the number of files is incredible. It takes time to locate the file and physically copy it."

The average hospital stay generates a 100-page record, she said. The 30-day window also allows for any outstanding test results and information to be added to a file to be sure it is complete.

Then there's the fee, which is dictated by state law. There is no charge for a record to be transferred to a physician's office. But if you want a personal copy of your medical record, there is a $10 search fee, and a $1 per page charge, with a limit of $250 per hospital admission.

Every institution and practice also must have a policy in place to address a patient's inability to pay for records. "If patients can document that they are on welfare or Medicaid, for example, the fee is waived," said Gansfuss. "Fees may change when we all go to electronic record keeping, but that will be some time coming."

Today and tomorrow

Most hospitals and doctor's offices are behind the curve in applying technology to record-keeping - or even working on a system-wide computer network that allows sharing of information across medical departments. Most records are physically kept in boxes; more recent files in the hospital and older records in an off-site storage location.

"It can take up to two hours for me to get the records I need for a patients from another hospital or doctor," said Ash Nashed, a physician who is assistant director of emergency medicine at Morristown Memorial Hospital. Nashed's practice group uses an electronic charting system that stores patient records electronically, a method he finds fast and effective.

The Medical Center at Princeton is one of the few hospitals in the state that uses automated order entry reporting, which allow doctors to directly type into the system when they order tests or medication for a patient, for example. The hospital-wide system communicates the order to the appropriate department and sends the results back to the doctor.

Every user has an access code, which secures the patient information. "From a patient's point of view, an electronic system makes it much easier to access medical records," said Ken Knieser, the hospital's vice president for finance in charge of information systems.

While 90 percent of Princeton's residents have gotten with the program, attending physicians still prefer handwritten notes to data entry.

The market is being flooded with dot.com companies eager to assist in keeping electronic track of your personal medical records. CertifiedMail.com is a Springfield-based online service that allows patients to communicate medical information via a secure server, with an electronic "receipt" indicating that the message has been retrieved from the company's site. The basic service is free; adding a password-protected component that further secures the encrypted message costs $99 per year.

"Most people don't realize that the average e-mail is about as private as a postcard," said Mahout Michael, president of CertifiedMail.com. "Do you really want to take the chance of sending confidential records electronically without any safeguards?"

MDChoice.com, medical content search engine that is physician reviewed and approved, will offer free encrypted e-mail for the transfer of medical records and sensitive information beginning in February.

"Electronic records are where everything is going," said Nashed, CEO of MDChoice.com. "Ultimately, patients benefit when their multiple doctors can easily and confidentially share information about their medical history in the course of care."

PersonalMD.com offers consumers a way to create and manage their medical records online. An advantage to PersonalMD.com is that the service accepts faxed information directly into your personal record, and can be remotely accessed by fax as well as e-mail. The service is free, with banner advertising, and is used by more than 84,000 patients and physicians.

"Not everyone has access to a computer, but you can find a fax almost anywhere in the world," said Alan Zwerner, senior vice president of PersonalMD.com. "People travel allover the world. Being able to access all current health data about yourself from anywhere is invaluable. It also makes it easier to move from physician to physician if you have chronic or multiple conditions."

New technology designed by a California company called Medweb will make it possible to print all imaging tests, such as X-rays and ultrasounds onto a tiny disc the size of a credit card, which can then be downloaded on any computer CD-ROM.

"The world's changing," Zwerner said. "It no longer makes sense to have records sit in 100 places on thousands of pieces of paper."

Understanding your records

The very nature of medicine makes it difficult for a layman to understand a medical record. Figure in the fact that most doctors still write notes by hand and the process becomes even more daunting.

"It makes sense to work closely with your primary care physician to understand your records," said Dr. Louis Teichholz, chief of cardiology at Hackensack University Medical Center. "Somebody has to have an overview. Procedures vary from practice to practice; there really aren't universal standards to help a patient figure it out on their own."

And while there are no secrets in the records, a patient might draw the wrong conclusion or become unduly concerned if he or she misunderstands something. "If a lab result is one-10th of a point off of the normal scale, it might say the results were abnormal. Improperly interpreting something like that can cause unnecessary anxiety for a patient and their family," said Teichholz.

Typical medical records can include a laundry list of things to sift through, such as hospital admission and clinical records, physician order sheet, patient history sheet, physical exam record, medication record, lab results and summary reports.

Two Web sites helpful with abbreviations are www.geocites.com/HotSprings/9837/abbrev.shtml, and an online medical glossary, sponsored by the American Medical Association, at: www.ama-assn.org/insight/gen_hlth/glossary/index.shtml.

When attempting to read your own medical records, get help from qualified professionals. And then seek medical advice before making any decisions based upon the information.

"At the very least, carry a list of the most important information in your wallet," said Teichholz. "One reason patients should have more information is to provide for better care. That's really the bottom line."

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