Can Patients Scan Multiple Medical Tests, Lab Results, and Doctor Notes for Combined Review?
Yes, patients can and should be able to scan in multiple medical tests, lab results, and doctor notes for combined review, as modern electronic health record systems are specifically designed to facilitate the integration of patient-generated data while maintaining source identification.
EHR System Capabilities for Multi-Source Data Integration
Electronic health record systems must facilitate the integration of patient-generated data and must maintain the identity of the source. 1 This fundamental requirement ensures that:
- EHR systems should enable collection of data and interpretation of information from multiple sources by clinicians as appropriate and necessary, including nuanced medical discourse, structured items, and data captured in other systems and devices 1
- The provenance of all data in the clinical record must be recorded and managed along with the data, allowing physicians and other healthcare professionals to trust the data by understanding its source and the route it took 1
- Systems must support "write once, reuse many times" functionality and embed tags to identify the original source of information when used subsequent to its first creation 1
Patient Access and Data Sharing Benefits
- Patients are increasingly able to access their laboratory results via patient portals, with potential benefits including reductions in patient burden and improvements in patient satisfaction, disease management, and medical decision-making 2
- Transparent health records allow patients to read notes to be better informed and check accuracy, with approximately one-third of patients reading notes specifically to verify correctness 3
- Information extraction systems can successfully correlate lab test results from clinical notes with structured lab data, achieving high accuracy (F1-scores of 0.964-0.967) for glucose and HbA1c extraction 4
Critical Implementation Requirements
When patients provide scanned documents, the following safeguards must be in place:
- The system must clearly identify the source of each piece of data to allow clinicians to assess reliability and context 1
- Clinicians must be able to view related information without having to navigate away from their working window 1
- Systems should provide clear takeaway messages for each result and signal whether differences are meaningful or require action 2
Common Pitfalls to Avoid
- Lack of universal electronic medical records can lead to duplication of tests when providers cannot access previous results, resulting in unnecessary repeated examinations 1
- Without proper source documentation, patient-provided data may create confusion about reliability and clinical significance 1
- The most frequent cause of abnormal test results is physiologic or laboratory variation, not underlying disease, so context from multiple sources is essential for proper interpretation 5
Clinical Workflow Integration
- EHR systems should support joint patient-provider decision making, team collaboration, and care process management when reviewing combined data from multiple sources 1
- Documentation should include the patient's narrative in sufficient detail to accurately represent their story, potentially including entries from the patient when permitted by regulations 6
- Prospective flow sheets, retrospective medical record review, and electronic medical records are all valid sources of data for comprehensive patient assessment 1