You’ve probably observed your doctor or nurse taking copious notes during office visits. These clinicians’ records comprise your patient chart and include information relating to treatments you’ve received, conditions you’re managing, dates of wellness checks and vaccinations, and results of lab work that you’ve had while in their care.
When these charts exist in digital form, they’re referred to as electronic medical records (EMRs).
When your EMR is stored in a system that includes your medical data from other providers such as specialists, it is part of your electronic health record(EHR), which represents a larger patient footprint.
The information in EHRs is meant to move with the patient (referred to as “interoperability”) to provide context for future practitioners and help inform treatment plans in order to provide better care. Unfortunately, while many hospitals maintain EMRs they aren’t yet effectively implementing EHRs, meaning that when you change healthcare providers your records stay put.
And It’s not uncommon to switch healthcare providers. That can happen when you:
- Move to a different city or state
- Get a new job (which often means new health insurance)
- Switch individual health insurance plans due to affordability during open enrollment – 29% of people using healthcare.gov in 2015 switched to a new insurance plan.
- Turn 65 and require the care of a geriatrician (a doctor that specializes in treating older patients)
- Become eligible for Medicare
So what do you do when you switch providers and your new doctor doesn’t have any of your previous patient history and records?
That’s where your personal health record(PHR) comes in.
In this article, you’ll find out what a personal health record is, what kind of information to include on your PHR and how this documentation can help protect your health and finances. (Go right to How to Create a Personal Health Record.)
What is a personal health record?
A personal health record is a file or folder that you create and maintain, containing all of the important medical records generated throughout your life. With an up-to-date personal health record you will be able to accurately share details about your medical history with your healthcare providers or insurance companies (if required for a health questionnaire).
There are many ways to create and maintain a personal health record. You could:
- Save electronic versions of your medical records obtained from the hospital in a file on your computer or on a shared Drive (like Google Drive)
- Organize hard copies of information in a three-ring binder or file folders
- Enter everything into a PHR software or app on your smartphone or tablet
What do you track in your personal health record?
You’re the one creating a record of your personal health, so ultimately decisions about what should be included in the record are up to you. Your goal should be to make the record as exhaustive and comprehensive as possible. Don’t leave anything out!
Here’s what to track in your personal health record:
- Name and Date of Birth – Most people visit a hospital for the first time on the day they were born. Make sure that your personal health record is clearly matched to you by including your name and date of birth.
- Blood Type– If you ever need an emergency blood transfusion, the extra time it takes to draw a blood sample and send it to the lab to determine your blood type could seriously affect the outcome, and you’d be surprised how many people don’t know their blood type.
- Date of last Physical Exam– Most people forget to go to the doctor for their annual physical examination, but it’s important from a disease-prevention standpoint to get checked out each year. Maintaining a record of when you had your last check-up serves as a reminder to book your next one.
- Dates and Results of Tests and Screenings– All of our bodies are slightly different, and maintaining detailed records of any tests or screenings you undergo helps to establish a benchmark for how your body normally functions, which can be useful if you start getting sick and doctors need more data to make a confident diagnosis.
- Major illnesses and Surgeries– Remember to include dates, along with the nature and results of any medical procedures you undergo.
- A list of your medicines, dosages and how long you have taken them– If you are taking any medications on a regular basis, or have in the past, that information belongs in your personal health record. If you experience a medical emergency, knowledge of what medicines you take can prevent EMS personnel from giving you contraindicated drugs that could make things worse.
- Allergies– Many people go for allergen testing where they are assessed for up to 50 or more allergies at once – but are you likely to remember all of the results in five years? If you take your child for allergen testing, adding it to their personal health record means that they’ll have the information needed to protect themselves from substances that could cause anaphylaxis or even death.
- Immunization Records– You need to know what shots you’ve had. If immunizations are offered at your child’s school, they need to know whether they have had them already or not. When your child grows up, they will need to definitively know what immunizations that have had. Keep records!
- Current Medical Conditions + Chronic Diseases– Recurring problems or illnesses should be documented in the personal health record, along with dates and conditions of flare-ups and any related trips to the doctor’s office or hospital.
- Family History– A growing body of evidence suggests a strong genetic component for disease. You have a vested interest in understanding what illnesses have impacted your family in the future and tracking them so you can take steps to mitigate your risk factors for developing the same issues in the future.
- Provider Bills + Insurance Company Claims– With some estimates as high as 80 to 90% of medical bills including errors, the problem of incorrect billing is all too common. This can have far-reaching consequences on your wallet and credit score. It’s important to obtain these documents (especially an itemized bill) and closely compare your medical bill against the insurance claim (and your insurance benefits statement) and work to resolve any discrepancies you find as quickly as possible. Keep all these records, including proof of payment once the issue is resolved.
What are some personal health record benefits?
You may trust your healthcare providers to make the best decisions for you, but you will ultimately bear the consequences of the decisions they make, so it makes sense to be as informed and engaged as possible.
Maintaining a personal health record signifies a paradigm shift for most people – from taking a passive role in their healthcare to a more active one. Here are some benefits of maintaining a personal health record:
Become a pro-active participant in your healthcare decisions
Healthcare needs to be a collaborative effort between providers and patients. A personal health record empowers you to have discussions about any treatment plans or tests you’re considering with your current physician because you can easily reference procedures, tests, diagnostics, or even recommendations and advice that you received in the past (including what did and didn’t work).
Effectively coordinate your health care with specialists
A lot of health conditions and symptoms require coordinated care across multiple providers such as imaging labs, specialists and primary care physicians. When you can’t count on medical institutions to share your patient files, your PHR can help ensure your entire care team has all the information in order to provide treatment that is as safe and effective as possible.
Get your new primary care physician up-to-speed quickly
Don’t rely on your memory to recall prescription medications (including dosages and frequency), past medical procedures (including when and where) and your family’s health history. You’ll be able to provide a much more accurate picture of your personal and family health history with a PHR and it will make that first appointment with your new provider easier for you both!
Utilize alternative health care providers like virtual doctors + convenience care clinics
We have more options than ever to obtain routine health care. You don’t need to make an appointment at your primary physician’s office and wait to get a camp physical for a child, or a sinus infection diagnosis. These kinds of services are increasingly being performed via pharmacy walk-in clinics and virtual doctor’s visits.
The services are typically competitively priced (even if you have to pay 100% out of pocket), convenient and accessible for a lot of patients (with evening and weekend visits at the pharmacy and 24-hour access to telemedicine), making them an obvious alternative for many patients.
The downside is that the nurse practitioner at your local Minute Clinic probably doesn’t have access to your EMR. Your personal health record helps ensure that these practitioners have the information they need to provide you safe and effective diagnosis and treatment plans.
Want to learn more about the convenience of virtual doctor’s visits? Learn more about Telemedicine.
Access your health records while traveling
Traveling without your personal health record can be risky. If you have a medical emergency while away from home and no way to get a hold of your medical records, a doctor treating you will have to learn everything about you based on what you can tell them. Establishing your own medical records that you can share with them means that they’ll have much more information to use when designing a treatment plan or prescribing medication to help you get well.
Access information even when your doctor’s office is closed (such as during a medical emergency)
With a few swipes on your phone the ER nurse attending the gash in your arm can quickly see what medications you’re taking (have taken in the past), and any pre-existing conditions or allergies you have.
And that may make a difference in terms of the speed and quality of care you receive when you unexpectedly find yourself in the emergency room, and especially if you’re there for something critical. When that information isn’t available (because it’s midnight on a Saturday and your doctor’s office is closed), the PHR you maintain on your phone could be a literal lifesaver.
Are you covered in case you have an accident or critical illness that lands you in the ER? Major medical plans include ER visits as one of the essential health benefits, but if you’re between plans you could be facing big out-of-pocket costs in the ER, anywhere from $700 on the low end up to $6,000 or more. An alternative health insurance plan like short term medical can help for 30 to 364 days (duration limits vary by state) if you need coverage for the emergency room.
Learn more about what short term health plans cover.
Record your progress toward health-related goals
If you want to improve at something, you have to be able to measure it over time. Otherwise, how will you know if things are getting better? Whether it’s getting your weight down, reducing your body fat, lowering your bad cholesterol count or increasing your iron intake, maintaining your personal health record establishes benchmarks and helps you track your progress towards better health.
Maximize the value of physician instructions + test results
This may have happened to you: You go to the doctor for a routine appointment and they draw some blood and send it out for testing. The results come back a few days or a week later in the form of an email telling you to access your results at your portal.
You’re then left to try to interpret the results (or the laboratory short-hand) and figure out what this snapshot in time means and what to do next. It’s at this point that it can be easy to assume that you’ll be contacted by the hospital if there are concerns and move on to the next thing. And while it’s probably true that your provider will contact you if they see red flags, it doesn’t help you maximize the value of these test results or proactively protect your health. When you’re maintaining a PHR, you will download the results, add them to your records and compare with your previous lab tests (from last year, 5 years ago, 10 years ago, etc.) and see if you spot a trend, especially a trend that you may wish to reverse, such as increasing levels of LDL.
If you have any questions or concerns about the trend you’ve spotted, contact your doctor for a follow-up phone call to discuss treatment options. Maybe you can adjust your diet and avoid having to go on cholesterol-lowering medication if you take action now? But no one other than you will be able to spot that trend.
Avoid unnecessary preventive care
The flip side of maximizing the value of the care you receive is identifying care you don’t require and not obtaining unnecessary medical testing and treatment. This is also important for good physical and financial health.
Keep track of dates and notes from annual wellness checks (more frequent for developing children), vaccination records, and routine test results to ensure you’re getting enough care but not spending your time and money on unnecessary appointments and testing, especially when you switch providers.
A record of your appointments, including hospital bills and insurance claims can be useful for writing off medical expenses on your taxes. Efficiently maximize your tax write-off by maintaining records throughout the year.
Make decisions about health insurance + apply easily
Maintaining personal health records (including a record of your insurance claims) can help you track your usage of healthcare services and insurance over time to determine what health insurance plans are right for you.
For example, if you see a pattern of visiting the doctor a few times a year for minor conditions such as a cold, you may want to consider a Telemedicine plan for low-cost medical consultations over the phone.
Or, if you notice that over the years you’ve required more prescription medications, a drug discount card could help reduce your prescription medication costs.
You may recognize that you’re using your health insurance but never quite reaching your deductible, not uncommon with high deductible health plans. Supplemental benefits such as a hospital or medical gap plan may help manage out-of-pocket expenses.
You may also be required to provide your medical history for some types of insurance, but remember, major medical insurance is “guaranteed issue,” meaning that you can’t be denied coverage because of your medical history or pre-existing conditions.
Are you ready to create your own PHR? Get started now!
Learn how to create a personal health record and find out what medical records apps can help make the process even easier!