Personal health records make medicine more patient-centered

One of the easiest ways to make medicine more patient-centered is to routinely ensure that patients have access to the information in their own medical records, including their medical history, laboratory results, diagnoses, and treatment plans. Going a step further, patients also can be encouraged to add to the record—including results of past medical tests, or information about their personal medical histories, such as diseases or conditions, medication allergies, blood type, family history, etc.

Aniruddha Malpani, MD“Allowing patients to review and provide feedback about their records can provide you with valuable information that can enhance their care.”
-Aniruddha Malpani, MD, medical director of Malpani Infertility Clinic in Mumbai, India

At present, most doctors and hospitals in India do not allow patients to see or contribute to their own records. In other countries such as the United States, more and more healthcare providers are seeing the benefits to allowing both doctors and patients to access medical records and provide input.

This type of collaboration is often called[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] a “personal health record” (PHR). In the United States and other countries that are already widely using electronic health records (EHRs), the records are often maintained electronically by healthcare providers, and patients can access and modify the information through a secure Web site with password-protected patient accounts. Even if you don’t yet have an EHR or other electronic repository system, you could do something similar in your practice by giving patients access to their paper records and encouraging their input.

Key Point: Collaborating with patients to maintain medical records helps educate patients and enhances communication. Patients can add information to their records such as medical history, drug allergies, blood type, family history, and other pertinent facts. They can also provide feedback if something contained in their medical record is inaccurate or complete, which can enhance the care that you provide.

Allowing patients to review and provide feedback about their records can provide you with valuable information that can enhance their care. For example, after taking patient histories and formulating diagnostic and treatment plans, I read the information back to patients so that they know what’s contained in their own medical records. I always make entries in front of my patients—and explain to them what I have written, so they know what’s happening.

This simple practice has multiple benefits—for my patients and for me:

  • It empowers patients by involving them in their treatment. It shows that I respect them, and that I’m willing to explain what is happening. It helps to demystify their medical treatment, and they learn that medical terms don’t have to be a foreign concept—they can make sense to them.
  • This process also ensures that I do not forget important medical details. If I do so inadvertently, my patients will correct me promptly. This interchange can help reduce medical errors.
  • Explaining the medical record is a great tool for improving doctor-patient communication and ensuring that we have the same priorities and are headed in the same direction.
  • Collaborative personal health records are also an effective way to manage risk. Explaining the record to the patient is an excellent way to document that patients know what’s happening and that the facts and treatment options have been explained to them.

Giving patients access to their medical records and encouraging a collaborative PHR is just another means of ensuring effective doctor-patient communication. When you and your patients are communicating, the end result is always better for you—and for your patients.

Aniruddha Malpani, MD Dr. Malpani is medical director of Malpani Infertility Clinic in Mumbai, India, medical director of the HELP-Health Education Library for People, and author of a physician and patient education blog. He is an angel investor in Plus 91, which offers customized Web sites for doctors.


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One Comment

  1. Hari varadappan
    Posted Nov 2012 at 12:50 pm | Permalink

    Dr Malpani has hit the nail on the head in saying ”Personal health records make medicine more patient-centered” and his views in this article emphasizes the slogan;Listen to your patients,Learn from their experiences and perfect the art of ”putting patients’ care at the heart of whatever you do”.

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