Half of those who had received mental health care found errors and omissions in their medical records
Physician and advisor Bo Wang and her colleagues want to raise awareness among both healthcare professionals and citizens. - We need a better understanding that the language in patient records meets several needs.
What do users think about the content they can read in their own patient records from Norwegian hospitals?
Is there a difference in what people answer based on whether they have received treatment for physical illness or mental illness? Do they find errors, omissions or descriptions they don't like in the medical record?This has now been investigated by doctor and advisor Bo Wang and her colleagues at the Norwegian Center for E-health Research.
The study was part of an international project. The aim was to investigate users' experiences of access to electronic patient records in Sweden, Norway, Finland and Estonia.
Researchers in the four countries used the national health portals where they invited people to respond to an electronic survey.- The Norwegian survey was posted on Helsenorge.no in early 2022. People who were logged in were invited to respond. Around 9,000 people responded. The majority were women. Approximately 7,000 of them had received treatment in somatic health services. 2,000 had received help for mental disorders, says Wang.
She was particularly interested in the experiences of those who had received mental health care. The reason was that few people have done research on it before.
36 percent felt offended
The researchers got answers to why users read their medical records. They also found out whether they had received treatment for a physical or mental illness.The most important reasons for reading their own medical records were to get information about their health and treatment. They also wanted to make sure they understood what the doctor had said.
One category of questions dealt with errors, omissions and offensive descriptions in the medical record.
- There were many answers in this category, also in free text. It was clear that the questions engaged more people, especially those who had received treatment in mental health care, says Wang.
At the same time, a larger proportion of those in mental health care said they found errors in their medical records compared to those in somatic services. The figures here were 49 percent versus 27 percent.
Those who had received treatment in mental health services were more likely to find offensive comments and omissions in their medical records than those in somatic services. The most serious errors were found in medical history, communication, diagnosis and medication.
Only one in four people informed healthcare professionals about what they thought was wrong the next time they met.
In addition, 36 percent of those with experience of mental health care reported that they felt offended by something they read in the medical record. 12 percent of those surveyed in somatic health care said the same.
One person who had received treatment in psychiatry wrote the following:
“I was diagnosed with emotionally unstable personality disorder without any kind of assessment ... which made the whole of psychiatry turn its back on me and refuse to help me, even though this diagnosis is invalid.”
Another user described their experience of being disrespected or overlooked:
“The therapist described me in the journal with personal characteristics such as disinterested and absent ... I was scared, in pain and felt run over, I contacted the therapist to have this removed, but did not even get a response.”
Some of the respondents wrote that they reacted to being called overweight. They particularly reacted to this when weight had not been a topic in the consultation with the doctor.
Others pointed out that it should be easier to correct incorrect descriptions in the medical record.
In need of training and skills development
What can be done to solve the challenge of record keeping and users' negative experiences when reading the content?Previous studies have shown that people find it good and useful to be able to read their records. It strengthens trust and collaboration. Read more about this in this article:People feel more in control of their health when they see their medical records
In Norway, all patients have the right to access their medical records.
At the same time, research shows that healthcare professionals can be skeptical about giving patients access to everything. This is especially true for people with mental health problems. They can become anxious or confused by reading the documents.
- The ethical issues are difficult. Access to medical records is necessary and required by law. We should take steps to ensure that doctors, nurses and other healthcare workers have a better understanding that the language they use in medical records must meet several needs. Healthcare professionals don't just write for each other. The patient is part of the communication,” says Wang.
She believes that healthcare professionals should learn more about how the medical record has evolved from being internal documentation to becoming a transparent part of the interaction.
The language must be objective and not judgmental. Students must be aware that disagreements will arise between therapist and patient. They already have such training in some places.
- It's a new way of thinking. The transition is not easy and requires effort. It will probably take time before we see the changes, says Wang.
She says that citizens should also be given better information about what the medical record is used for. They should be prepared for the wording they will encounter.
- The fact that patients can discuss this openly with their therapist can contribute to better understanding, says Wang.
Reference:
Bo Wang mfl.: Users’ Experiences With Online Access to Electronic Health Records in Mental and Somatic Health Care: Cross-Sectional Study. J Med Internet Res., 2023. Sammendrag. DOI: 10.2196/47840