It happens every day in emergency departments across the country: A patient is admitted who is incapable of providing a coherent medical history and/or the person accompanying them also cannot provide adequate medical background.
Our job as emergency physicians is to diagnose the patient promptly and to provide appropriate treatment. When we do not know the patient — which is virtually all the time — and when they cannot tell us about their medical history, the challenge is especially daunting.
Electronic Health Records (EHRs) have been an important advancement in providing complete and accurate patient information; in fact my colleagues and I have been vocal advocates for their implementation and use. The days of literally calling the medical records department so that you can view a paper record are thankfully gone forever.
Current medical histories help us establish an accurate working diagnosis and treatment plan. With a patient’s medical history in hand, we can learn if a patient with chest pain has ever had heart problems, whether a patient with gastrointestinal pain has chronic digestive issues and whether a patient is taking a drug that may be contraindicated with drugs being considered as part of the treatment plan.
The importance of physicians having access to patients’ medical histories is well-recognized on the national level. The U.S. Department of Health and Human Services (HHS) has made significant efforts to make medical information more accessible. The HHS Office of National Coordinator for Health Information Technology (ONC) website says, “When health care providers have access to complete and accurate information, patients receive better medical care. … With EHRs, providers can have reliable access to a patient’s complete health information. This comprehensive picture can help providers diagnose patients’ problems sooner.”
Therefore, it is difficult to understand why the ONC is proposing rules that would allow medical information to be hidden from physicians. In a new rule, the ONC is proposing to require clinicians the ability to redact discreet pieces of medical information from the medical record created on a prior encounter, if requested by the patient. This proposal is essentially legalizing tampering with the legal medical record and therefore decreasing transparency — and increasing risk during subsequent care events.
While the proposal is a well-intentioned effort to give patients more control over the confidentiality of their own medical histories, the practical effect will be to increase the likelihood of an inaccurate diagnosis and treatment plan.
For example, if a patient hides their past opioid use, how can an emergency physician (or any physician) know to avoid prescribing opioids? If a patient hides their past violent behavior, the emergency team could be at risk. If a patient hides their mental health history, a physician might prescribe an anticonvulsant unaware that the patient is already taking drugs that could interact. ONC’s proposal could even halt automatic systems in the EHR, such as flagging harmful drug-drug interactions, if the patient has requested a prescription be hidden.
Given the many variables in medical treatment, the possible risks to patients are endless when a physician does not have access to complete medical information. Further, rather than reducing stigma, this policy could instead encourage it by reaffirming that a history of depression or a sexually transmitted infection is something that should be hidden.
As physicians, we have an obligation to keep patient information confidential. Not only is it a matter of law that includes fines, it is central to our oath as a physician to do no harm. For emergency medical teams (or any physician), limiting access to a patient’s complete medical history can only result in delayed diagnosis and treatment at a time when quick diagnosis and treatment is critical. Hiding medical information can easily lead to less effective outcomes for the patient.
Over its history, the ONC has taken several steps to create a culture of enhancing transparency and the value of EHRs. While the bipartisan 21st Century Cures Act has recently made huge advancements in making patient information available to clinicians, this regulation takes steps in the opposite direction and should be reconsidered, modified or — preferably — deleted. Giving patients an option to hide some of this information from physicians is a step backward for sound emergency and medical care.
Dr. Kevin Baumlin is chief medical affairs officer at the University City Science Center in Philadelphia. He is a former professor of emergency medicine at Penn Medicine; professor and chairman of the Department of Emergency Medicine at Mount Sinai Beth Israel; and associate medical information officer at Mount Sinai Health System. He is Board Certified in Clinical Informatics and Emergency Medicine.