The clerical aspect of data collection rarely makes the immediate list of concerns for licensed medical professionals.
However, what data you collect, how you collect it, how you distribute it and who can access it are a few of the common, overarching issues you may personally encounter.
They also remain a larger issue for the healthcare industry as a whole, in Illinois and nationwide.
[Related: Third-Party Payer Interference in Patient Care]
Why Medical Data Collection Stays Fragmented
The way the industry collects data is one component that makes the data itself problematic. A patient may see multiple providers or go to multiple medical facilities. They may use their insurance for certain visits, while other visits go uncovered.
How does a patient’s medical history from one hospital visit reach their file at a completely different hospital or doctor? What happens when they visit a facility in an entirely different city, state or even country?
Each facility collects data on the patient and retains it within its own system. However, these systems sit isolated from one another, subject to the protocols of the specific facility the patient visited. Other facilities can “order” that history, but the process runs inconsistently and can consume time the patient needs for proper treatment.
[Related: Misdiagnosis Claims Can Lead to License Discipline]
Why Patient Self-Reporting Falls Short
In addition to the isolated nature of medical data collection, patients often have to self-report their entire medical history to help guide their treating physician. Patients prove unreliable for a range of reasons.
Shame, guilt and embarrassment keep some details out. Other factors drive inaccurate patient data:
- Forgetting visits
- Inadvertently omitting information
- Misremembering specific medical issues
- Losing track of medications they previously used
- Being unable to pin down dates, times and facilities
When a patient enters a treatment facility, the medical professional may simply rely on that patient for a relatively accurate snapshot of their medical history. That snapshot is unreliable.
[Related: How Healthcare Professionals Should Handle Disrespectful Patients]
What TEFCA Has and Has Not Changed
For years, this happened because the country had no systemwide medical data program. That’s changed, although not completely.
The Trusted Exchange Framework and Common Agreement (TEFCA) now operates as a nationwide framework for sharing health information. The HHS Office of the National Coordinator for Health Information Technology created it to remove barriers to sharing records electronically among providers, patients, public health agencies and payers.
The first Qualified Health Information Networks (QHINs) were designated in December 2023. Data began moving among them within days.
Participation still runs through networks that organizations choose to join, so coverage varies by region and by system. The conglomerate report that a patient could easily hand to the person treating them doesn’t yet exist.
[Related: How To Keep Patient Information Private]
Where the Medical Data Ethics Question Stands
The ethics of mass data collection on a particularly sensitive topic held these programs back for years; those concerns still shape how far the framework reaches. TEFCA answers part of them by setting common privacy and security requirements across participating networks, including for organizations that HIPAA doesn’t cover.
The industry may not put this at the forefront of many minds and may rank it below other hot-button issues. Even so, the utility of collecting and sharing medical data ethically and effectively deserves more serious consideration going forward.
Until the picture fills in, medical professionals remain at the mercy of a patient’s willingness to share their medical history and their ability to remember it. That’s on top of relying on other healthcare facilities to provide the information they hold.
[Related: Does an Illinois Physician Have To Submit to Questioning by an IDFPR Investigator?]
How Incomplete Patient Information Turns Into an IDFPR Complaint
The gap between what a patient tells you and what actually happened doesn’t stay theoretical. It shows up in your decisions, then in your chart, then in someone else’s file on you. Common paths include the following:
- Prescribing without a complete medication list, which can look negligent once the full picture surfaces
- Charting a history that reflects what the patient recalled rather than what took place
- Missing an allergy or contraindication that another facility documented years earlier
- Delaying treatment or repeating a test because records from another provider arrived late
- Answering a records request with a file that strikes an Illinois Department of Financial and Professional Regulation (IDFPR) investigator as thin
None of this requires wrongdoing on your part. The IDFPR doesn’t weigh whether the gap started with the patient, with another facility or with systems that never connected. Once a complaint arrives, your chart becomes the evidence, and the chart belongs to you.
[Related: Why You Need an Illinois Professional License Defense Attorney if You Are Under Investigation]
Protect Your Illinois Medical License With Williams & Nickl
Questions about records and documentation rarely arrive on their own. They tend to surface once someone else has already raised a concern about your care.
At Williams & Nickl, we’ve represented thousands of licensed medical professionals before the IDFPR and the Illinois State Medical Board. We’re happy to fight in your corner.
Call us at 312-335-9470 or contact us online to schedule a free, confidential 1-hour consultation.
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