Transferring Health Information Still Slow

Every time I write about patients obtaining copies of the lab reports for their records, I always receive two or more emails telling me to stop as this is not necessary and they can always be transferred if the patients moves and transfers doctors. Some doctors are very possessive of patient's records and others are not and almost insist on the patient having a copy.

Even some patients do not want a copy of lab reports and don't know why they should have a copy.

Therefore, I will repeat myself – always ask your doctor for a copy of all lab reports and in addition, if you have an operation, ask for a copy of all reports pertaining to the operation.

I like that Dr. Leslie Kernisan complains about patients not maintaining at least a rudimentary personal health record. Here is her explanation:

1. Some of the problem is culture and habit.
2. The other problem is that so far it hasn’t been easy to maintain a personal health record.
3. What a lay person needs for the info to be easy to review might different from a clinician’s usability requirements.

Many people are aware of the idea that clinicians are the people who keep our health information and it is their responsibility to send this information to others when necessary. The problem here is that many clinicians fail in doing this.

Often other clinicians need to obtain the necessary information from other clinicians and then put it in physical records or digital records. Finally, the information needs to be easy to review.

Number 3 above does make sense for those patients that don't want copies of their medical records or lab reports. However, many clinicians would appreciate copies of lab reports because then they at least have some information about the patient until the transfer of records can take place.

Dr. Kernisan says, “I can’t help but think that by now it should be easier for people to get and keep copies of their health info. And it should likewise be easier to share or move health information, or at least allow another provider to access the data.”

In trying to obtain some records from my past, most of the records have disappeared when the doctor retired or died. Fires were the most common cause and it could never be determined if they were set or accidental. The police reports had also been lost. One doctor's records still existed and I was able to obtain a record of the diagnosis of my allergy to sulfa drugs and some sulfa derivatives, which the doctor tested. These were from October 1945. No records exist from 1952 to 1972. Some records from 1983 to 1994 no longer exist.

Thanksgiving Day is 'Tenth Family Health History Day'

This is an idea that should be adopted by every family. Many families do not wish family history to be passed to their children and refuse to talk about it with others. This is not a good thing for their children and grandchildren. However, this secrecy is often difficult to overcome. If it hadn't been for my father, there would probably be many things about my mother's side of the family that I would not know. Even one of mother's sisters was kind enough to affirm what I was told and added a few additional facts.

The following is part of one page on this site to complete the information. Because I will not complete the information or start this, I am not allowed access to additional pages. I will continue to maintain my record book and not use their site. That is my personal preference.

I don't mind how you keep track of your family history records. The important thing is that you do it for your sake and the assistance you will provide for your children. Many people are too stubborn and leave no information for their offspring or for dedicated caregivers. They don't appreciate the fact that people might be spared needless worry and might have a clue that could save a doctor precious time. In addition, this might give the doctor relevant information that could save your life if acted upon timely.

Having covered this information, I am left with one problem. If you chose not to correct the information that your doctor has on you, you may not get the correct treatment when needed. The doctors often believe the information they have in their computers is correct and up-to-date when in fact most electronic medical records (EMRs) and/or electronic health records (EHRs) are far from correct.

I know from reviewing my electronic health record, there are some serious errors. I recently received access through a patient portal (their term) and in reviewing my record discovered several medication errors and medical history errors. Now I am on a mission to get them corrected. The first comment I received from one doctor's office was that it is correct and they were not changing it.

I am now composing a letter and I will hand deliver it with the corrections spelled out. This will start the clock and then if the records are not corrected, I will be forced to contact the correct officials to force the issue. I will also need to update my medical power of attorney to reflect the possible errors and provide the new copies to those I have designated to act for me if necessary.

The Trip to Obtaining Your Medical Records

Now that you are ready to obtain copies of your medical records, make a list of each doctor, period that you were a patient of this doctor, and whether the doctor is still alive or still in practice. Then make a list of medical labs you have used or that your doctors has used, whether they are still in business or not, and locate their address. The purpose is if your doctor is deceased, you may need to contact the labs for test results. Not the best solution, but this may be all that is available to you.

To obtain copies of medical records, you have to be the patient, or the parent of a minor child or the legal guardian of the patient for whom you seek medical records. If you are a caregiver, you may be able to obtain medical records if the patient has provided a legal medical power of attorney to the provider. Verbal authorization generally is not sufficient, but may work for some providers for a limited time. Forget about inquiring or obtaining medical records for your spouse, children of legal age, or parents without legal authorization.

The US Department of Health and Human Services provides background information to help you understand who may, or may not, be able to access your medical records. Providers are required to follow the state rules in which the records are kept. Generally, this means for an adult medical records are kept six or more years. Most children's records are kept three to 10 years beyond the age of 18 or 21. It is always wise to contact the provider to see if the records are still available.

Your doctor or provider is required to share any notes or records they have created or any test results which they have copies. Any information provided to them by another doctor is accessible if that information was used for the diagnosis or treatment being discussed with you. Diagnostic lab tests are a little more complicated, as blood tests, CT scan, x-rays, mammograms, or other tests should be requested from the doctor who ordered them, or from your primary care physician. In most states, the lab will refuse to provide them directly to you. For other records such as hospital records, clinics, or any other medical facility, be sure to request the copies directly from them.

When it involves mental health and related records, this is an area where many doctors will refuse you access. If they do, they must make the reason for denial clear in writing.

Many patients unfortunately believe they or their legal representatives are the only ones that can get copies of their medical records. This is false; there are people that can legally gain access to your medical records without your permission.

When you request copies, most practices, offices, or hospitals will have a form to complete to receive a copies of the requested medical records. They normally will send it to you by fax, email, postal mail, or you may pick it up from the doctor's office. If the facility does not have a specific form, you may write a letter, but be sure to include the following information:

• your name, including your maiden name (if applicable)
• make sure that you date the letter for the date of delivery if possible
• your social security number
• your full date of birth
• your complete address
• your phone number or cell phone number
• the list of record(s) being requested
• the date(s) of service when you were under this doctor's care
• delivery method preferred – pick-up, fax, email, or other method
• your signature

Deliver the letter or mail the letter to the doctor's office. If you deliver, record in your own records the date the date of delivery and it might be beneficial to have a second copy that the person receiving the letter can sign, date, and show their title.

Now we come to the problem of gettingrecords from a doctor that has sold out, merged into another practice, or had simply left the practice (whether died, quit, retired, or another reason).

If your doctor has left the practice or sold the practice or it was combined with another practice, then the new practice should still have your records. If this is the case, follow the same procedure above as if the doctor was still working in that practice.

If your doctor is no longer in practice, or for some reason you cannot locate the doctor or office where you think your records should be, there are some steps you can take to locate your medical records. These steps include:

1. Contact your local medical society. You may be able to look up the phone number online or in the phone book, or you may find the contact information you need through this list of medical societies in each state. You will need to drill down by state to your local society.

Someone at the medical society should be able to let you know what became of your doctor's practice, and will possibly know where the doctor's records are being housed. They may also be able to tell you how to get copies if the procedure will vary from the basic procedure described here.

2. If your local medical society does not have the information you need, then contact your state medical society association, as per the list linked in #1 above.

3. Finally, if the medical societies cannot help you, then begin contacting other practices of the same specialty in your area. Some doctors will ask other practices of the same specialty to house their records when they close their practices. The idea is, that if your doctor is not in business any longer, then the other specialist might want to pick you up as a patient.

Simply call the office of each of the other same-specialty doctors and tell them, "I was a patient of Dr. ____'s. I am hoping to find my medical records. Can you tell me if Dr. _____ gave them to your practice?" If they say yes, then ask their protocol for getting your copies. If they say no, then ask if they know where those records are being kept. If they do not know, then call the next same-specialty practice and ask them the same question.

4. Finally, if none of these possibilities work out, contact the hospitals in your area. Unless you can determine a better department, then try Human Resources. They may know where your records are being kept.

Keep in mind that when your records have been housed elsewhere, they will be difficult to retrieve unless they are among the minority of records that have already been transferred to an electronic health record. For that reason, you will very likely be charged for the copies you want.  Learn more about how much you may have to pay for copies of your medical records.

Your Rights to Obtain Medical Records

This is a topic I started in November2010, and you may review it here. Georgetown University maintains a list of states and the rights for patients in each state that may be in addition to your rights under HIPAA. Please take the time to review the rules for your state, as these are important and can sometimes answer many questions. There is a lot of information available on obtaining your own medical records or those of your minor child. In some states, once the minor attains the age of sixteen, parents may have limited rights.

HIPAA (Health Insurance Portability and Accountability Act) of 1996 created a lot of privacy, but also mandated that covered entities must provide you with copies of most of your medical records. Of course, they may charge you a reasonable fee for them. Some doctors, hospitals, and insurance companies do their best to wear you out as a way of discouraging you and prevent themselves from providing the records.

If you are denied access to your medical records, then you must take steps to obtain them. I will provide the steps necessary, as I understand them. You need to check them and follow them carefully and then if you are denied, you need to file a complaint.

The steps you need to follow are not that difficult, but for many, it can be a nightmare if you meet with rebuffs at every step.

1 - First, make sure you have a right to the records. This is not always as easy as this sounds. Even your own records may become unavailable to you and beyond your legal reach.

2 - Second, be sure that you follow the right steps and procedures for obtaining your medical records. You will need to sign in person the request and follow directions. So make sure you listen to what you are told as this can take several days or even a week or more depending on where the records are kept and personnel available. Most entities will not accept a phone call, and will ignore these requests.

3 - Third, be sure you have made the request from the correct facility. Do not go to the clinic for hospital records. For outpatient records, you may have to ask the doctor who keeps them.

4 - And fourth, have you waited long enough? This is where the state you live in can determine the length. Federal law mandates the longest wait they can delay giving you your records at 60 days.

Many walk-in clinics and places that do not file for insurance reimbursements are not considers covered entities under HIPAA and as such not required to give copies of medical records. Be sure to ask even then as a few will as a courtesy. Be prepared to pay a reasonable fee.

Once you are sure you have met all requirements and are still being denied access to your medical records, you will have 180 days to file a complaint once you are denied. This complaint must be filed with the US Department of Health and Human Services. This information will be in another blog later.

For more explanation, you may want to read this reference.