Electronic Corrections

One of the wonderful things about computerized word-processing is the ease with which corrections can be made. A file can be accessed, changes made, and the revised document can be printed out within minutes. The ease with which someone can do this is matched by the risk of what can happen if the wrong person gains access to the electronic files containing a patient's medical records.

If you have a chance, rent two movies: Sneakers and WarGames. Each film demonstrates what can happen when a computer hacker accesses a file and changes its contents. A talented hacker might be able to alter his high school grades, someone's bank records, or a person's medical record.

With the trend toward the computerized patient record gaining momentum, security checks pose an increasing challenge with regard to proper and safe maintenance of medical records. In order to understand the risk involved, you must first understand something very basic about electronic word processing.

Suppose a transcriptionist has finished a report whose file name is report.doc and transmitted that file to your office (or to a hospital's Medical Record Department) over the telephone lines. The file named report.doc is now sitting somewhere on your office computer's hard drive (or the hard drive of a computer at the hospital), waiting to be printed out in its original format.

If that file does not reside in a password-protected subdirectory, anyone who knows how to use the word-processing program on that computer has the power to access the file and make alterations in its contents. If the altered file is then saved under the same file name (report.doc), the amended version will write over the original version of the file and the original will be lost.

To avoid such problems you must establish a system whereby any document that is altered must be stored under a new name -- and include an indication somewhere in the revised document showing the date of alteration and who made the alteration. Otherwise, you will not have a copy of the original. If the transcriptionist only maintains archives for a limited period of time, you will have no ability to compare the document to its original.

A spin-off problem, of course, is that multiple copies of each document will have to be stored on the hard drive. This requires more and more disk space. If you follow the mathematical progression through one year's alterations, you will understand why the computerized patient record is a goal which will not be achieved immediately:

Not every facility has that much storage space!

Next: Dictating For Another Physician

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