Originally published in The Ottawa Citizen September 24, 2002
Original Title: Copy Capers

A recent Dave Brown column touched upon the thorny issue of patient chart transfer requests. He cited the case of one individual who expressed his irritation with transfer fees that he felt should be free of charge. Copyright law analogy provides the basis for his assertion. His claim is that patient chart notes are paid by the patient through taxation and as such did not belong to the physician. The physician writing the notes does so for the patient who subsequently owns the record.

The crux of the issue is not who owns the charts. It is the expectation that all medical and administrative services should be free. OHIP pays for medical, not extra-administrative services. In some instances considerable secretarial time is spent collating the documents. Odd-sized lab report paper cannot be automatically fed through the photocopier feeder and require manual single sheet copying. The chart notes and lab results are sorted chronologically and if necessary a covering note from the physician is placed at the front. Then it is mailed to the new physician.

This is not about copyright law. The medical records are not being published. The information contained within the chart belongs to the patient. They are entitled to a copy of their records. The physician requires their own original copy to best provide patient care and for medicolegal purposes. Records must be kept for ten years beginning from the date of the last patient visit.

It has been my experience that patients sometimes lose original documentation. Heck, they misplace prescriptions and ask for another an hour after I prescribed it for them! Mistakes happen. If the originals are lost, copied records are a poor substitute for purposes of legibility (multiple copies of copies degrade resolution) and original evidence.

The OMA provides guidelines for third party billing purposes where OHIP fees do not cover these services. It states in the OMA Physicians Guide to Third Party and Other Uninsured Services, Section 1, Para. (e): “Preparation and transfer of an insured person’s health records when this is done because the care of the person is being transferred at the request of the person or person’s representative. In addition to the office overhead, the physician may charge for his or her time in preparing the information for transfer.”

Where I part company with the guideline’s fee is thus: their recommended rate is $27.96 for pages 1-5 and $1.12 for each page thereafter. I know that the physician writes the notes but it is hardly worth the price of a thick novel. In our practice we charge $15 for pages 1-5 and ten cents per page thereafter. The average cost is about $20. For whole families, the $15 is waived for each additional family member. I believe this is a reasonable compromise.

There has to be a reasonable accounting for services and value provided for the fee. Our health care system has influenced the public’s expectation that all requests for services are free and therefore have no inherent value. This is especially true for sick notes or for telephone or fax prescription renewal requests. I do not agree that I or any physician should work for nothing. You would not expect the same from any other professional service that provides reports and information requested by an individual. If I request a transfer of my business accounting records from my accountant, I would receive a bill for the service.

OHIP pays the physician for the services outlined in the General Preamble of The Schedule of Benefits (physician billing code book), not the patient. The purpose of OHIP is to remove the barriers between doctor and patient by having a third party pay for the medical services. The physician does not have to worry about payment and the patient need not be hindered by lack of funds in seeking medical care. The doctor-patient relationship is protected by this arrangement.

The notion that the public pays my salary is not quite correct. OHIP is an insurance organization. Other insurance companies collect premiums from their clients. If the client has an accident or requires medical attention, the insurance company will pay the professional fees. Would one say then that all the clients pay the salary of that professional? Or is it the insurance company that oversees these funds and negotiates the best value for their dollar? Where does the circle of funding end?

Let us look at government contracting out service requests from independent businesses or third party individuals. Do we assume that these people are beholden to the taxpayer? Are they not independent businesses on contract to government? Is it not the government who is responsible for how the money is spent in-trust for the taxpayer? Where is the public outrage about the recent disclosures of misappropriation of federal monies?

The circuitous logic of where the money trail begins and ends and who owns the money is flawed. Frankly the basis for the whole issue centres once again on the insinuation that doctors are greedy and are looking for any angle to justify the extra fees. It is an issue that is demeaning to me and my profession.

I do not condone exorbitant fees for chart transfers. I do not withhold the chart if the patient does not pay. I rely on good faith and reputation as the carrot. There is no stick. I do not subscribe to the notion that because I am paid through OHIP, I am beholden to the whims and rages of the taxpayer. At some point the refrain “I pay your salary”, denoting control, loses its charm.

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© Dr. Barry Dworkin 2002