When a parent takes their child to a doctor or hospital, they naturally trust that the medical records accurately report the child's medical history, symptoms, diagnosis, and treatment. Families and treating doctors rely on the accuracy of medical records to make ongoing medical decisions and ensure continuity of care. Illinois State Representative Dan Caulkins has introduced a bill to ensure that Illinois residents are directly notified within three business days when their medical records are altered. He filed the bill in response to concerns raised by Garrett Discovery, a digital forensic firm with a healthcare forensics division, who reported that patients are often unaware that their records have been changed.
Several federal laws regulate the management of medical records, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, and the 21st Century Cures Act of 2016. Each of these acts were enacted to protect patient data and to give patients greater access and control over their electronic medical record (EMR).
There is growing awareness that hospitals are not complying with laws regarding the management of EMRs. Last year, in Prieto v. Rush University Medical Center, it was revealed that the plaintiff's child's medical records had been altered in an effort to conceal that the hospital's actions caused the child to suffer from hypoxic ischemic encephalopathy and respiratory distress syndrome during birth. The judge ruled that parents have a right to obtain their child’s full EMR and that a hospital’s failure to release a full EMR, complete with the audit log and revision history, is a violation of the Supreme Court’s discovery rules, as well as federal information blocking regulations. Numerous hospitals are currently under investigation by the U.S. Health and Human Services Office of Inspector General (OIG) for information blocking.
“After some research, I found that some healthcare providers are putting limitations in their medical record system to filter out alterations so that the patient never knows and sometimes this is done by those that are not practicing medicine,” said Rep. Caulkins. “The Cures Act did not address healthcare facilities altering records and failing to notify patients of those alterations. This bill aims to protect Illinois residents from this bad practice and improve patient access to their own medical records.”
The Family Justice Resource Center (FJRC) supports this legislation and believes that it will not only improve patient care and safety, but also help prevent medically-based wrongful allegations of child abuse and neglect. This legislation will help protect Illinois children and families by:
Ensuring accurate medical records are provided to parents
Allowing parents to know if their child's records have been altered after the date of care, and the reason for alteration
Ensuring that prosecutors and courts are basing their decisions on the full and complete medical record
Requiring the release of audit trails and logs to show all additions, deletions, modifications, and other changes
Providing the legal system with stronger tools to punish those who alter records to cover up misdiagnosis and medical errors
FJRC Executive Director, Michelle Weidner, says, "This bill is a common sense measure that everyone can get behind. Medical facilities who are doing the right thing should have nothing to hide."
You can watch the full press conference online here.