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Vol I: Your Right to Know

When I started volunteering at St. Mary’s Hospital two years ago, I was placed in the outpatient department. Most of my job involved sorting and stamping charts, and delivering them to different departments of the hospital. In training, the secretaries couldn’t emphasize enough that I must never let a patient see their own chart. Failure to comply with this strict regulation would result in immediate expulsion from the volunteer program. On one occasion when I was walking past the waiting area to deliver a chart, a patient asked me if she could see her chart. Everyone was appalled, as if asking such a question were as egregious as me picking up her chart and reading it aloud. I apologized and said that it is against hospital policy.

Six months later, I was “promoted” to the Medical Day Center, where there is much more patient contact. At first, like in the Outpatient Department, the charts were all gathered in numerical order on a trolley behind the secretary’s desk. Whenever a physician needed a chart, he would get it himself and then put it back. At the end of the day, sometimes, I would be in charge of pushing the trolley to Medical Records. But things were soon to change.

I fondly remember about a year ago, after six months in the Medical Day Centre, a kindly woman in a volunteer uniform dropped by the Medical Day Centre. She passed around a few pens with papers that rolled out detailing everything patients need to know about their rights. She said she was from the new Patient Advocacy Team. There were numbers patients could call if they felt their rights were being compromised, and a statement that said: “Every patient is allowed access to their medical records. If you would like to see your chart, drop by medical records or call this number to make an appointment.” This was a pivotal moment in my experience as a volunteer; the peripeteia that precipitated a revolution in how patient care and confidentiality of records was viewed. Or so I thought.

Things started changing slowly but surely in the Medical Day Centre – though I was unsure whether it was merely from an increase in awareness due to this newly implemented Patients Committee or from new regulations regarding medical records altogether. The “chart trolley” got smaller and smaller, and charts started appearing on the small rolling tables next to the patients’ beds, next to their lunch trays. They were free to peruse them at their leisure while waiting for the doctors to come.

Recently, after a conversation with a representative from St. Mary’s Department of Medical Records, I found the answer. According to her, the observed trend did not reflect a change in rules, as they had always been the same: “If a patient ever wants to see their chart, they are supposed to make a written re- quest to medical records. They’ll set up an appointment to view the chart. The waiting room environment of the Outpatient Department, for example, is the reason why patients are not allowed ac- cess to their charts, as, unlike in the Medical Day Centre, it is not supervised by nurses and there is a risk that they or an accompanying relative will walk out with it. The charts are the property of St. Mary’s, so they must remain here at all times.”

This rule was evidently put in place to ensure absolute confidentiality, something that is taken very seriously at the MUHC. According to the representative at St. Mary’s Medical Records, “Nobody is allowed to view your file without your written consent, so letting patients see their charts whenever they want also adds a small risk of the patient accidentally leaving the chart behind for other people to look at.”

Even doctors are not allowed to view a patient’s chart without the patient’s written consent. Meaning, any doctor in the hospital who is not follow- ing a particular patient is not allowed to see their chart with only one exception: If an emergency warrants immediate action, the doctors taking care of the situation are allowed to see the charts under the clause of either “inferred” or “forced” consent [1]. The former means that it is assumed that the patient would allow the doctor to see his or her chart if this patient were old enough, conscious enough, in less acute condition, or of sound enough mind to make the decision; and the latter means that the patient would be a menace to society if consent is not forced (Hunter v. Mann[1974]).

Confidentiality is absolutely crucial for any medical system to work, as, “if clinicians were not required to keep confidence, people would be reluctant to provide them with personal information about their physical and mental health. In the case of psychiatric patients, a proportion of whom might also be dangerous.[1]”

Anyone with statutory right of access is allowed to see his or her personal data [1]. In Quebec, this refers to anyone who is 14 years of age or older and is not a ward of the state. The Quebec Health and Social Service Ministry states that you are also allowed to request a hard copy of your chart free of charge, provided you have the proper identification (your RAMQ Health Insurance Card).

The year 2011 marks a pivotal year for medical recordkeeping in Quebec. Starting this year, paper medical records are going to be transferred to an electronic database [2]. This initiative, already commonplace in Europe and strongly pushed by both the Bush and Obama administrations in the US, hopes to reduce the cost and environmental impact associated with the collection and maintenance of paper records. CTs, MRIs, and X-rays, among other test results, are already in an online database at all McGill affiliated hospitals, so it seems perfectly logical for the rest of patients’ charts to follow suit. However, such a large-scale change seldom comes without its opponents. Many people fear that placing medical records online would render them susceptible to hackers and other intelligentsia. The Quebec Ministry of Health and Social Service addresses and refutes this point, claiming it is not a legitimate worry as all information would be stored under tight security, and will be backed up in such a way that in the very unlikely event of hacking or system breakdown, an accurate copy of the records before their vandalism or breakdown would still be accessible [2]. Moreover, Dr. Brian Jacobs from the Childrens National Medical Centre in Washington, D.C., claims that the benefits of storing medical records electronically far outweigh the risks. He raises a valid point in stating “the root of most medical errors is miscommunication. With electronic records, we can prevent that.” For instance, anyone who knows a pharmacist knows that it’s definitely not a myth that a large proportion of doctors have illegible handwriting. With the new electronic system, prescription errors due to bad handwriting would be a thing of the past, and test results can be accessed quickly and easily by any practitioner who needs them [3].

The Quebec Electronic Health Records (EHR) website states that authorized health professionals who have at least limited access to your chart includes doctors, nurses, microbiologists, medical archivists and pharmacists, as long as they are personally responsible for your care. The government hopes to expand the list of “authorized personnel” to dentists, nursing assistants, podiatrists, optometrists and midwives. Another new development starting in 2011 is the restriction of your employer, insurance company, or person from seeking to have you sign a contract that requires a health assessment or to request even a partial copy of your EHR. This is for the purpose of alleviating any burden, financial or otherwise, that disclosure might cause. So if any employer requests access to your medical records, you are required by law to refuse them access without penalty[2].

For more information about your rights to your medical records, consult http://www.dossierdesante.gouv.qc.ca.

Alexandra Markus is a U1 student currently majoring in Physiology and double-minoring in Drama and Theatre and Social Studies of Medicine. Global health has always been a passion of hers, primarily thinking up creative yet practi- cal ways of lessening the health burden in developing countries. This summer, she will be going to Peru with Patch Adams et al. to clown around, paint murals, and of course, run a clinic.

References

  1. [1]  Dolan, Bridget. (2004). Medical records: Disclosing confidential clinical infor- mation. The Psychiatrist, 28, 53-56. doi: 10.1192/pb.28.2.53. Retrieved Feb 18, 2011 from http://pb.rcpsych.org/cgi/content/full/28/2/53.
  2. [2]  Minist`ere de Sant ́e et de Services sociaux du Qu ́ebec. (2011). Dossier de Sant ́e: Pour mieux prendre soin de vous. Retrieved Feb. 18, 2011 from http://www.dossierdesante.gouv.qc.ca
  3. [3]  Silberner, J. (2009, March 29). Electronic Medical Records A Charged Debate. National Public Radio. Retrieved Feb. 18, 2011 from http://www.npr.org/templates/story/story.php?storyId=102481028.
This article was originally published in the Spring 2011 issue, and can be seen here.
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