When Jerry Cohn travels, his medical records from The Nebraska Medical Center go with him safely tucked away in a shirt pocket, wallet or passport. He wouldn’t have it any other way and neither would his doctor. At a time when President Bush is calling for better electronic medical record keeping, Cohn is seeing it at The Nebraska Medical Center.
Jerry, who underwent major heart surgery a few years ago, finds security in his medical information CD given to him by John Windle, M.D., chief of cardiology for The Nebraska Medical Center and chairman of the cardiology section in the UNMC Intermal Medicine Department.
“I would encourage all of my patients, especially those who travel, to obtain a CD of their medical records,” Dr. Windle said.
“We think it’s just great,” said Cohn’s wife, Soralee. While in Arizona a few months ago, Cohn ended up in the hospital with heart problems. Rather than try to remember what tests he had undergone, Cohn’s wife, Soralee, gave the Arizona doctors a computer CD containing his medical record.
“It didn’t end up being anything serious,” she said. “But having that disc made everything a lot easier on us.”
That is exactly what the CD is designed to do. Unlike a smart card that needs a special reader, the medical information CD can be inserted into any Windows-based computer armed with a CD drive and Internet Explorer. The CD starts itself when inserted into the computer and a menu of options allows the user to quickly access the various sections of the medical record.
“A patient can take the CD to just about any health care provider in the country and expect their health care record to be accessible to the treating physicians,” said Thomas Tape, M.D., internal medicine physician at The Nebraska Medical Center and professor in UNMC Intermal Medicine-General Medicine.
On the CD, the patient and health care providers will find basic identifying information, a list of the patient’s medical conditions, allergies, medications, recent laboratory results, X-rays and other diagnostic testing reports as well as office progress notes, inpatient admission notes, surgical notes, discharge summaries and consultation reports. That is important information for doctors who don’t know you.
“Very often, patients who become ill when away from their regular physician receive less than optimal care because the treating physician has limited knowledge of the medications the patient may be taking, results of recent lab tests or is unaware of important medical conditions or allergies,” Dr. Tape said. “The lack of information is made worse when the patient is very ill or severely injured and unable to provide an adequate medical history. The treating physician with access to the CD would be able to see virtually the same information as the local physician with full access to the computerized medical record.”
The medical information CD is free of charge to cardiology and internal medicine patients at The Nebraska Medical Center and can be updated after clinic visits, lab tests or inpatient stays. Because the medical record CD is given only to the patient, who can then decide who else gets to see it, privacy laws are protected and the Heath Information Portability and Accountability Act (HIPAA) is not violated.
Patients have the option of assigning a password to gain access to the record, although many choose not to do it in case they become incapacitated and unable to give the code word to a treating physician.
“Because the patient has the record, they are truly in control of their medical information,” Dr. Windle said.