Study: Patients’ health records may not reflect doctors’ orders


A rare heart abnormality may seem noteworthy in patient’s medical record.

But a recent study shows roughly 60 percent of those with the problem had no record of it even after three months of physicians discovering it. Another 30 percent or so lacked the information on their health record after three years.

The study’s authors, including some UI faculty members, say there could be a number of reasons for this.

“This is a pretty complicated problem,” said Peter Cram, a UI associate professor of internal medicine who participated in the study.

Released Tuesday in the Annals of Internal Medicine, the study was conducted at the Veterans Affairs Medical Centers in Iowa City and Omaha.

Of the 4,000 patients in the study, a fraction were found to have an aortic dilation — a heart abnormality — through a CT scan, Cram said. Researchers found lags in updating patient files following the medical tests.

UI spokesman Tom Moore said most tests — such as radiological images, which include CT scans, MRIs, and X-rays — are reported to the patients within several days. Because the images are digital, they can be stored immediately.

But there could be variations based on the testing volume.

“The limiting factor would be how many scans the radiologist could review and interprtion were not severe enough for doctors to find it urgent to include in medical records; the study did not find any patients who were harmed as a result.

Because of study limitations, some researchers said they cannot answer that question, however. Scientists only looked at whether the doctors documented evidence of seeing the abnormal test — they did not inquire why they didn’t.

Doctors generally see approximately 30 patients a day, which makes it difficult to keep track of all the different medical records they receive via phone, fax, computer, and mail, Cram said.

“Doctors order a lot of tests, and for every one of those tests, someone needs to actually get the result, review it, and decide if it’s important to not and get back to the patient,” he said.

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