Are your medical notes a bible of truisms about you, or merely a set of earlier errors, writes Sheilagh Foley?
I am within the midst of a home renovation which required us to pack up and decamp to a rental home. This concerned some overdue purging and eccentric flights of fancy down reminiscence lane. In a single field I discovered my deepest darkest secrets and techniques….my medical file.
After all, I poured over it with a cup of tea in hand, reminiscing about this tumour and that operation. I’d pull out some black and white photographs and suppose ‘Ah, take a look at how my insides have been, they’re all grown up now!’
Every so often I discovered myself stopping mid-read and saying to an empty room “Eh, that’s improper”, “That didn’t occur”, “I by no means mentioned that”. My most alarming second was once I uttered “Oh expensive, they’ve put down the improper kind of most cancers”.
After an e-mail, a cellphone name, and a letter, I’ve been assured that the actual hospital in query has corrected my file to point the right most cancers in my historical past. I might sound pedantic however there are completely different outcomes and coverings for these completely different cancers, if I land into the hospital incapacitated some day I don’t desire a medic studying inaccurate paperwork and making choices as I’m whistled into theatre.
I additionally requested the identical hospital to contemplate a extra minor correction, however impactful nonetheless – it pertained to 1 cellphone dialog I had with an admin hospital worker, she had taken it upon herself to make an observation in my chart that I used to be “A really anxious girl”. I requested the hospital to take away the observe as I used to be not an anxious particular person, the hospital declined to make the change.
I don’t thoughts what folks consider me or observe, however I’m uncomfortable being advised how I really feel (solely an individual themselves is aware of how they really feel – in that cellphone dialog I used to be not an anxious particular person however an individual pissed off with delays, lack of communication and mis-communication). In a court docket of legislation telling an individual how they really feel is inadmissible. I might apply the identical logic to a medical file. On this circumstance I discovered the descriptor prejudicial.
My gripe could seem neither right here nor there however what’s written in our affected person file shall be learn by the following physician and nurse and inform their opinion of us. It may possibly throw doubt and disbelief (dare I say hysterics) over a real bodily and even psychological downside (or perhaps a official grievance of care). For the file, I used to be high-quality with references within the file from actual medics relating to how I’m coping (anxious or nicely), their feedback have been written as contextual observations having really handled me in particular person, normally over a protracted interval.
In one other letter from a unique hospital a health care provider famous that he had spoken to his colleague about me and that I had advised her I had a household historical past of cancers, which defined why I had succumbed to multiple most cancers. I don’t have a exceptional household historical past of most cancers, I’m conscious of the physician he’s speaking about, and I didn’t have that dialog together with her. My second most cancers is straight associated to the remedy from my first most cancers, it’s not familial or genetic. She might have been pondering of a unique affected person – however now the untruth is on my file.
Everyone is human and errors occur, however these errors pertain to our well being. A collection of medical notation errors can erode the belief we now have in these taking care of us.
I believe it’s unhappy in a approach that our medical file, a tome devoted to us, doesn’t bear a whisper of our personal voice.
With enhancements in GDPR and freedom of data, sufferers are gaining access to their notes so I think about the observe makers are bearing this in thoughts once they ascribe one thing to a file. After each appointment, check, scan, and many others I ask for letters, experiences, and whatnot. I then overview them myself. In equity, it’s seldom that I see a mistake, however sometimes I do.
Whereas vitals, lab outcomes, and imaging are typically thought-about goal, even their interpretation can have a subjective factor.
In recent times I had a radiologist describe a bone break as as a consequence of my fragility. There’s nothing fragile about me, it was as a consequence of an accident. If he had checked out my latest DEXA he would have seen these bones ain’t made for breaking. I’m guessing he simply checked out my age and thought, feminine over 45, I’m stunned she will stroll down the highway with out snapping like a twig.
Nonetheless, I respect it will be cumbersome and a logistical nightmare to have sufferers proof-read each letter, remark, observe that goes on their file.
Enter AI.
I haven’t seen this but in Irish hospitals however in sure American hospitals there are AI medical scribes at work that may observe what the affected person is saying, what the physician is saying, and the way it relates again to the scans on file. They will even put collectively a abstract. Maybe the affected person, in addition to the physician, might have permission to log out on the abstract. It may very well be carried out by way of an app in your individual time.
I don’t imagine AI ought to change or supersede our healthcare professionals. There’s an artwork to drugs you could’t programme right into a machine, and this artwork will contain subjective judgement. However medics working alongside AI provides an assistant to the method, capturing the information precisely, and retaining the affected person’s perspective in play. A health care provider’s scientific impression can also be one thing that’s subjective, however we must always respect it as an skilled opinion. My issues are errors and inaccuracies logged right into a file that over time develop into an unchallenged truth.
If a health care provider felt a affected person can be reviewing their notes would they begin having official notes and unofficial ones? Maybe no person has time for that degree of skullduggery, though, if one have been to create a medical app for these illicit whispers, you can name it ‘Skullduggery’ – I’d obtain that.
Additionally, urgent file on a dialog might take away the chat and banter that a health care provider and affected person might get pleasure from as a part of their pure bonding and trust-building. After all all visible cues is not going to be captured by AI (not but, at the very least).
However as an correct file keeper and dependable truth checker, AI has obtained it occurring.
Maybe the best AI answer can be for the pc scribe to fact-check the newest assembly abstract to the entire affected person’s file historical past and flag any inconsistencies e.g. the affected person or physician has famous no household historical past of diabetes, prior notes present a household historical past, and so forth.
I believe AI ought to help and never change people. I don’t need a pc diagnosing me, however I might really feel snug if AI threw collectively a abstract of my visits with medical doctors. I’d even let the physician have the primary shot at reviewing it, including/altering/deleting as they see match. Then over to me for my sign-off.
Maybe, the larger query is, if AI makes a mistake, and each physician and affected person log out, in the end who then takes the accountability for the error?
I’m declaring AI as the answer however beneath all of it I’m calling for a extra collaborative and clear method to medical note-taking. Correct information are usually not only for the affected person’s profit, however for the integrity of the healthcare system as an entire.
Additionally, folks don’t respect being advised how they really feel, not to mention seeing it on paper years later. For those who suppose somebody is anxious, as an alternative of scrawling that of their file, perhaps ask them how they really feel and why.
Don’t be alarmed in the event that they reply that your AI scribe is stressing them out. No person likes an earwig (one other nice title for a scribe app).
Whether or not we go the AI route or begin working collectively, it’s time our medical information advised our story, not another person’s. 
