Newman's Notions | January 2009 | FREE
Most ACP Hospitalist content is available exclusively to ACP Members. This article is free to the public.

Just for the record

A computer crash prompts reflection on EHRs.

We were on hospital rounds, stamping out disease, when every clinician's nightmare occurred; the electronic medical record system crashed. How were we going to review prior admissions, compare old labs or see previous X-ray reports? We might be forced to ask the patients themselves to provide information! Even worse, we might have to resurrect the overstuffed, misfiled manila folders and clipboards of years past.

Luckily, the system popped back up and we were back to the old “cut and paste.” The scare prompted us to contemplate the history of the medical record systems.

Ancient records

Physicians have always documented individual cases and how they were managed. The Hippocratic Corpus contains many cases, some of which had bad outcomes. Even earlier, the Edwin Smith Papyrus circa 1600 B.C. documents 48 cases of clinical surgery, each with a standard arrangement of information, examination findings, semiology, diagnosis, prognosis and treatment.

The 20th century

Though there were many specialists in ancient times—Egypt was overrun with them—medicine in the last century became increasingly a group effort. In tracing this development, we can turn to Henry Plummer, MD, and the Mayo Clinic. In the early days of the Clinic, each physician and department kept data in independent ledgers. As the number of patients grew and patients returned to see other physicians, this ledger system became difficult to navigate.

That all changed in 1907, when Dr. Plummer devised the dossier system, which assigned each patient a unique serial number on arrival. All of a patient's records, physician notes, and exam results were stored in an envelope. Cross-indexing of the records by disease, surgical technique, and pathology allowed access to cases for research and presentation.

The continuity of this indexing system enabled the Mayo Clinic to build an archive of records that could be used for epidemiologic study. Communication between clinical departments was markedly improved. In the first year, 7,000 serial numbers were assigned. That number has since increased to more than 7 million today!

The electronic health record

Despite Dr. Plummer's innovation, records became increasingly disorganized, lost, and generally suffered from “chartomegaly.” In the early 1960s, computers began to appear in hospitals, but were used only for financial data management. Individuals such as Lawrence Weed, MD, in Vermont, a pioneer in the field of medical record management, and then larger institutions, such as the LDS Hospital in Utah and Massachusetts General Hospital, developed early electronic health record (EHR) systems, recognizing their potential value in managing patient information.

Initial investment stalled due to the high cost and low return of these early systems, which were slow and unreliable. Administrators and physicians alike balked at the expense and perceived potential logjams in workflow, unclear financial benefits, and concerns about physician autonomy. Progress in EHR development remained slow as computer science advanced but, as the costs of equipment decreased inversely to the power of operating systems, EHRs became a more viable option. The 1991 Institute of Medicine report, “The computer-based patient record: An essential technology for health care,” emphasized the need for changes in current medical record practices. It also outlined what EHRs should achieve. This stimulated an international renaissance in EHR development. A 2003 report by the IOM listed the “key capabilities of an electronic health record system,” which included the following: improving patient safety, supporting the delivery of effective patient care, facilitating the management of chronic conditions and improving efficiency.

Modern times

In his 2004 State of the Union address, President George W. Bush said, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” A Health Information Technology Plan was proposed. The problems noted that might respond to adoption of EHRs were: the then-current cost of care, ($1.6 trillion), uncertain value of the care delivered, medical errors, variable quality, administrative inefficiencies and poor coordination. The proposed solution, with the goal of assuring that most Americans would have EHRs within 10 years, would be aided with various governmental stimuli.

Perhaps the perfect EHR is in development somewhere. It's two steps forward, one step back. Many systems are still electronic versions of paper records. What was once cutting edge, the dossier, now looks like a relic from an ancient civilization. Someday, a medical anthropologist may uncover the remants of our pre-EHR hospital rounds, written not in hieroglyphics on papyrus, but hand scrawled and stuffed, out of order, into a manila folder.