Doctors Often Missing Patient Information

Key data not there for 1 of every 7 visits, study finds

TUESDAY, Feb. 1, 2005 (HealthDayNews) -- Too often, doctors don't have all the information they need to treat patients properly, a new study finds.

Reviewing more than 1,600 doctor-patient encounters in an eight-month period in 2003, researchers at the University of Colorado Health Sciences Center found important pieces of clinical information were not available in almost 1 out of every 7 visits, according to a report in the Feb. 2 issue of the Journal of the American Medical Association.

Specifically, laboratory results were missing in 6.1 percent of all visits, radiology results were not available in 3.8 percent of visits, while information on medication was unavailable in 3.2 percent of visits. Even basic information on a patient's medical history or physical exam was unavailable 3.7 percent of the time, the researchers report.

The information isn't there "because our health care system is not necessarily a system but a collection of private practices, health maintenance organizations and that sort of thing," said Dr. Nancy C. Elder, associate professor of family medicine at the University of Cincinnati, and co-author of an accompanying editorial in the journal.

"Most health care is provided by people who are loosely affiliated with various insurance systems," Elder said. "In my own practice, I am linked to seven or eight insurance systems. That means I have to deal with multiple hospitals, multiple laboratories, multiple x-ray facilities, and also with patients who are outside these systems."

The situation is somewhat better for people belonging to a health maintenance organization, where patient information can be available to all doctors in that organization, Elder added.

"But even in some of those, there is not always perfect communication," she said.

The study began with an investigation of problems in migrant health clinics, but it turned out to be "a near-universal experience for doctors and patients in general," said Dr. Peter C. Smith, assistant professor of family health at the University of Colorado, and lead author of the report.

The doctors questioned in the study said a lack of information often undermines the quality of care they are able to provide, Smith added.

"When providers were surveyed about whether they thought the missing information was likely to adversely affect patients, 44 percent said it would," he said. "Nearly 60 percent said it could result in delayed care or the need for additional services."

The problem of missing information was most common among recent immigrants, but it also occurred frequently for patients who had just changed medical providers or for those with multiple conditions, such as diabetes and high blood pressure, Smith said.

Such patients can be part of the solution, both Smith and Elder said. "They can really help out by being stewards of their own medical information," Smith said.

Patients who are moving geographically or changing health providers can ask doctors to provide them with copies of their medical records, Elder said.

"If copies of medical reports move with the patients, the doctors don't have to get them from the old health care system," she said. "A patient should have a doctor's office be aware of how important it is."

The federal government is trying to help solve the problem, according to Dr. Scott S. Young, director of health information technology at the Agency for Healthcare Research and Quality, which is part of the Department of Health and Human Services.

Last year AHRQ gave out $139 million in contracts and grants for improved health information programs, Smith said.

The agency is also funding state and regional health information projects, including statewide studies in Colorado, Indiana, Rhode Island, Tennessee and Utah, aimed at "helping to reduce the element of fragmentation," he said.

More information

SOURCES: Nancy C. Elder, associate professor of family medicine, University of Cincinnati, Cincinnati, Ohio; Peter C. Smith, assistant professor of family health, University of Colorado Health Science Center, Aurora, Colo.; Scott S. Young, director of health information technology, Agency for Healthcare Research and Quality, Bethesda, Md.; Feb. 2, 2005, Journal of the American Medical Association
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