In the spring of 2005, the Association for Healthcare Documentation Integrity (AHDI, formerly AAMT) launched the "Have You Read YOUR Medical Record?" campaign. This campaign set out to advocate for the profession and quality patient care documentation through public awareness. With the rapid evolution of technology, AHDI understood the importance of the personal health record (PHR) becoming a documentation option choice.

Since the signing of the Health Information Technology for Economic and Clinical Health (HITECH) Act on Feb. 17, 2009, the healthcare industry is coming full circle to resurrect this important message of the documentation experts. We are now starting to hear more from the healthcare industry and various healthcare associations who are pushing for patients to create and manage their PHR.

The HITECH Act was enacted to promote the adoption and meaningful use of health information technology. One of the requirements of meaningful use is having the ability to exchange health information with other providers as well as patients. With this Act, technology such as electronic health record (EHR) and automated speech recognition (ASR) tools are fast becoming more prevalent in hospitals and medical practices. While the intent for new technology is to open doors for increased efficiency and quality care for Americans, patients must also play a key role in guarding the accuracy of their PHR.

A recent ABC news article, "Grave Mistakes Costing Consumers Money and Time; Government Lists Living Americans as dead," discussed how the incorrect click of a mouse on a tax return can declare someone dead. Once it is in the system and duplicated, it can take an enormous amount of time to correct your record and remove the duplication of false information.

"It's very hard to prove you're alive when the paper says you're dead," Judy Rivers, a victim of data errors, said. Rivers said proving she's alive is a living nightmare. She's been denied credit, jobs and even her innocence. The Social Security Administration said it did not make the error in Rivers' record. But according to a 2008 Inspector General's report, data entry is the "primary source of error." 

Sound familiar? This article bears a striking resemblance to AHDI's message concerning the incidences of errors in the patient's health record. Where previous documentation experts served as an "essential" set of eyes upon the patient's health record, EHRs and ASR is becoming more common. Error rates could put patients at even greater risk, as many of the EHR technologies consists of point-and-click/drop-down box documentation coupled with ASR for more extensive documentation.

The American Roentgen Ray Society conducted a study that reviewed breast imaging reports from January 2009 to April 2010. The study compared ASR with conventional dictation transcription. From the 615 reports obtained, 308 were generated with ASR and 307 with conventional dictation transcription. The study concluded that reports generated with ASR are associated with higher error rates than reports generated with conventional dictation transcription.

With increasing documentation surfacing on error studies, it is paramount that patients also take an active role in the management of their health care.

In addition to patient safety and increased quality care, there are many benefits to becoming familiar with your PHR. The California Healthcare Foundation found that PHRs motivate consumers to improve their health. In a web article, "Utilizing the Promise of Personal Health Records," the American Association of Retired People (AARP) International says that PHRs empower consumers to make much more informed decisions about their health. With the launch of the "Have You Read Your Medical Record?" campaign in 2005, AHDI also created a toolkit and quick tips on how to read and understand your medical record.

Much like your Social Security number, patient medical records serve as legal documents. Medical records are released to health insurance companies for underwriting purposes, and coverage can be limited or denied if there is inaccurate negative information present. Your medical record is oftentimes utilized by potential employers, as well as various licensing agencies. By maintaining personal health records, patients can often avoid extra charges for repeated tests. When becoming active participants in guarding the accuracy of PHRs, patients can quickly correct medical errors in records before they get duplicated throughout the EHR.

It is comforting that the healthcare industry is helping to push forth the Association's vital message of "Have You Read YOUR Medical Record?" by encouraging patients to establish and maintain their PHR. In a sense, maintaining your personal health record is as vital as making sure you stay alive in the Social Security system.

Linda Giles is a transcription business owner who has been running her company, Transcription Etc., for the last 11 years. She also serves as an At-Large Director of AHDI.