Medical Records (Introduction to Medical Informatics) (http://www.cpmc.columbia.edu/edu/textbook) LAST REVIEWED: 22 September 1997 uses of the medical record (why formatted as it is) MAIN PURPOSE: facilitate patient care historical record for clinical care communication among personnel(continuity of care) preventive care (immunize, risks) quality assurance (deviation in babies weight) legal record (litigation, accrediting) financial (coding for bills, prove charges valid) prospective research (screening, tracking patients) retrospective research (look across existing records) history of medical records 1910 Flexner = advocated maintaining (patient-oreinted) records 1940s = hospitals need records to be accredited 1960s = electronic HIS: emphasize communication (routing orders & results) and charge capture 1969 Weed = problem oriented medical record (POMR) all diagnostic & therapeutic plans linked to problem 1980s IOM study of computer-based records 1990s managed care's need for computerized record need to know costs (to avoid capitation losses) need to control costs (guidelines) trend toward outpatient records inpatient record was structured first = regulatory requirement many people contribute to record (vs outpatient single lifetime family physician) reimbursement: more money per admission than outpatient visit now, more attention to outpatient records care by multidisciplinary team (therefore need to accommodate more & different data than before) managed care who enters data clerk primary physician, consultants nurse therapists, ... lab reports machines model (Hogan and Wagner, JAMIA 4:342-55, 1997) True State of Patient + + V + diag study + + V ++++++++++> clinician + + + V + V paper chart + dictation + + + V + V data entry clerk + transcriptionist + + + V V V chart representation of patient fundamental issues data capture: getting data from external sources can be difficult data input: entry can be time-consuming and expensive "free text" vs structured entry error: can occur at any point in entry model completeness: prop of observations actually recorded (30-100%, depending on type of observation) correctness: prop of recorded observations that are accurate (67-100%) security: tradeoff of access vs. security data entry transcription of dictation: very expensive, error-prone encounter form: various types free text entry scannable forms turnaround document: both presents and requests data direct electronic entry graphical: point and click free text typing voice query and surveillance systems examples: COSTAR's MQL; RMRS's G-CARE can be both query and event-driven event-driven does not depend on user interaction weakness of paper records find the record (lost, being used elsewhere) find data within the record (poorly organized, missing) read data (legibility) update data (where to record if chart missing) only one view redundancy (re-enter data in multiple forms) research (cannot search across patients) passive (no automated decision support) advantages of computer records (especially coded) access: speed, remote location, simultaneous use even if just a digitized picture of the paper chart legibility reduced data entry (reuse data) eliminate redundant entry eliminate redundant test ordering better organization by imposing structure allow multiple views, including aggregation example: summary report, structured flow sheet alter display depending on context automated checks on data entry more complete if prompt for data range checks (potassium=50) pattern checks (7 digit phone number) computed checks (sum of white counts=100) consistency checks (pregnant man) delta checks (weight increase of 100 lbs) spelling checks automated decision support reminders, alerts, perform calculations, advice on ordering limited by scope and accuracy of data in electronic format: tradeoff = data specificity/depth of advice vs time/cost of making record complete examples: COSTAR: improve tx of Strep and pos VDRL HELP: improve antibiotic treatment RMRS: improve preventive health screening cross-patient analysis research stratify patient prognosis, treatment by risks saves time 1974 study: find data 4x faster in flow sheet vs traditional record (where 10% of subjects could not even find certain data) data review: minimize overlooking uncommon but important events to work, the computerized record requires wide scope of data sufficient duration of use understandable representation of data sufficient access (number of terminals) structured data: o/w electronic record becomes giant word processor (though this still is better than paper) disadvantages of computer records initial cost (paper is already paid for) training delay between investment and benefit security concerns computer failures difficulty of data entry requires great coordination of disparate groups cannot always force data into computer's structure data diversity: accommodating different data elements, vocabularly, format, units, etc. EXAMPLES OF COMPUTER-BASED SYSTEMS COSTAR - outpatient Barnett at MGH in 1960s, originally for HCHP 1978 marketed, 1986 had 110 installations goals: improve availability and organization of record administrative, managerial, financial support modular design: security, registration, scheduling, billing, database, reporting uses encounter form for data input MQL for ad hoc queries can display data by encounter or problem public domain reports: encounter; status; specialty flowcharts Regenstrief Medical Record System (RMRS) - outpatient McDonald at IU in 1974 output: flowsheet summary automated reminders in QA report (1400 rules) uses encounter form for data input G-CARE medical query language The Medical Record (TMR) - outpatient Stead and Hammond at Duke in 1975 now 25 sites goal to eliminate paper emphasize capture and storage, also scheduling, billing data entry by clerks, prescriptions by MD display by problem, time, encounter Summary Time Oriented Record (STOR) - outpt and inpt Whiting-O'Keefe at UCSF turned on 1985 1988 60,000 records; 200,000 visits; 2000 queries/day goals: computer-based ambulatory record online display of outpt and inpt information flowsheets, graphs, charts, problems, treatments encounter form for visit can specify a granularity of time problem list can be nested subsequent lectures will cover the details of medical records related reading: McDonald CJ, Tierney WM. Computer-stored medical records: their future role in medical practice. JAMA 1988;259(23):3433-40.