On the Evolution of the Medical Record

He wouldn’t have survived. My father, that is, a general practitioner of 40 plus years who began practicing in the early 1950’s (see Inaugural). And the survival to which I refer? Whether or not he would have survived the transition from his office medical record system to an electronic one. Let me explain by tracing the path we physicians took with regards to the evolution of the medical record document by starting with the my father’s simple, but effective, system.

It goes without saying that medical records were handwritten for centuries. My father’s were no different. While confident that that there may have been some refinement in his medical record system over time, I can only spotlight the one he had in place when, as a medical student, I did an outpatient rotation (1979) in his office. The record consisted of a 5×8 lined index card upon which the date, chief complaint, and vital signs were written in by the nurse. After talking with the patient and completing a pertinent examination my father would fill in the blanks with a few historical comments, clinical findings, diagnosis, and either treatment or diagnostic studies to be ordered. So the information on the card would look something like this:

Oct 30, 1979 c/o: earache B/P 132/74 P 78. 2 day h/o throbbing left ear pain, low grade fever Exam: bulging red left TM, right OK, throat OK, H/L OK DX: left otitis media Rx: amoxil

Since he would see 40-60 patients a day (morning/afternoon/evening hours) he needed to record pertinent, brief, and concise information and the 5×8 card system sufficed. After the patient visit the card would be filed away until the next time. Thus was my introduction to outpatient medical record documentation.

I joined a single specialty (pulmonary/critical care) group in the summer of 1985. As we were a consultative service the understanding was that the initial consult, usually a letter to the referring physician, would be dictated but that any subsequent office notes were to be handwritten (dictation costs were substantial). The system worked but on more than one occasion it was a challenge to decipher a certain squiggle or abbreviation in the note, whether mine or one of my partner’s. Even so, patient care did not suffer.

Beginning in 1993 I moved to my second practice in Indiana. The multi-specialty group I had joined had a similar medical record policy, dictated notes/letters with the first patient visit, handwritten notes thereafter. Over time clinic sub-speciaists made arrangements with the clinic administration to allow us to dictate most, if not all, of our office notes in order to maintain our efficiencies in the office and permit us to better tend to our hospital and administrative duties. Dictation costs were always an ongoing issue, however.

My North Carolina practice (2008) had similar policies regarding dictation and handwritten notes. It was around this time, however, that the approach to medical record taking began to change for a variety of reasons. Payers were bemoaning the perceived lack of adequate documentation and health care providers were bemoaning the lack of access to medical records in order to provide timely care. With that in mind, allow me to say a few words about how things were and then comment on where things stand now.

Let’s first start with the purpose of the medical record. It is a repository of information, both current and past, in an effort to provide a story about a particular patient–the problem (history, etc), pertinent and succinct additional information, physical findings, pertinent diagnostics, diagnosis, and treatment plan. The record should then comment on the success (or lack thereof) of the treatment and what additional actions may need to be taken. Over time it can leave a legacy about the health history of any given patient that can be referred to on a periodic basis as may be required.

Regarding office records, whether it was my father’s 5×8 card, dictated reports or handwritten notes, payment by third party payers (private insurance, Medicare, Medicaid) was based on these. By these records doctors were essentially saying to payers, “Here is what I did; now pay me.” Third party payers would but, over time, began to feel (not without justification in some instances) that the documentation was inadequate to support the amount of payment. So different methadologies were developed and physicians were trained/counseled to try to keep up with the ever increasing and more complex documentation requirements. At its bare bones, the system consisted of a number of “bullet points” (e.g. histories {current, family, past medical}, exam {brief, pertinent, detailed}, medical decision making {simple, moderate, complex}). The more bullet points that ended up in the document, the better the justification for the charge. In many physician practices it was routine to have a compliance officer periodically review a physician’s notes to be sure they were “just right” as underbilling cost the practice money (third party payers were happy because they saved $) and overbilling could create a host of not inconsequential problems. The unwritten rule among physicians was if you were going to screw up the billing, underbill. The electronic medical record was touted as making billing better and easier.

Hospital records were also part of the evolutionary process from the written word to electronics. Initially most documents were handwritten with efforts to include the pertinent and avoid the superfluous (mostly successful on both accounts). In time many hospitals offered dictation ($$) for the admitting history, operative notes and, ultimately, discharge summaries. Hospital daily notes were different. Beyond the joke, many physicians have lousy handwriting and trying to decipher some squiggles in a note was frustrating and time consuming (the best interpreter of physician handwriting was the unit secretary). And hospital notes were often very brief. A surgical note might consist of nothing more than the comment, “Wound looks good; patient doing well,” but surgeons were paid a one time global fee for their service. A non-surgeon, however, was paid piecemeal, on work done on a given day which was justified by a note that better be more than just a one liner. Just as in the office, through the note physicians were saying, “Here is what I did; now pay me,” and, again, third party payers began to demand better and more complete documentation. Thus another impetus behind the electronic medical record (EMR).

Within the last 10 years there has been a huge push to implement an EMR. Congress appropriated millions of dollars to help physicians and health care systems purchase the hardware and software needed. Voice recognition systems became popular and so those entities with a computerized system could type their notes or dictate using a voice recognition system (while you could “train” the system to recognize medical terminology and phraseology often times what was said [despite training] wasn’t comprehensible to the system and gibberish would result–sometimes amusing but, obviously, confusing). Proofreading was always a requirement with dictation via voice recognition but could be laborious and time consuming and, with a full panel of patients, whether office or hospital, was often not done. Oh, for the days of “Battlestar Galactica” and Lorne Greene whose voice recognition system was perfect every time!

So, what are the positives about the EMR? Legibility of the note. Availability–no longer having to “hunt” for the chart (just a computer terminal). Quicker access to test results both current and historical as well as other historical information. More efficient rounding–prior to the EMR a physician would usually see one patient, write a note, and move on to the next patient. With an EMR a physician could now see a number of patients allowing more rapid assessments and interventions before sitting down to “batch write” their notes at one time. Off site review— If you were a physician in a (safeguarded) system one could review a patient’s chart or complete a daily note while at home (I knew any number of primary care doctors who would finish the day in the office, then have family time, and then spend time late at night completing their office documentation). If you were a physician receiving a patient transfer from another hospital in the system, pertinent records from the transferring hospital could be reviewed prior to the patient’s arrival. Payer review–third party payers could have an easier time finding their “bullet points”.

And the negatives of an EMR? Linkage–as software packages differ the EMR of one hospital system or physician practice won’t necessarily be able to “talk” with the EMR of a different hospital/physician system even if just across town, let alone in a different state, unless the software packages are identical and security agreements are in place. Cheating–hospital notes can be copied forward on a daily basis sometimes with minimal, if any, changes made thereby dulling the narrative. Hospital notes can begin to read like “War and Peace” when the requirements of a note, concise, pertinent, and to the point (a “Goldilocks” kind of note–just right) are ignored. Notes, whether office or hospital, can be preloaded with “bullet point” historical information and carried forward even though the information is not pertinent at that time. Most health care personnel make every attempt to do it right but there are some whose favorite words are “cut,” “copy,” and “paste.” Downtime–in the “old days” if a patient chart could not be located it was one chart and, while disruptive for that patient, no one else was affected. With an electronic system, if it goes down, then ALL charts are “lost” (at least for the moment) and significant disruptions on a variety of levels could occur until the system is restored. Cost–despite the previous federal subsidies I have no doubt that these systems continue to have an ongoing financial burden to any system or practitioner. Hardware, software, updates, support personnel to help the non-computer literate people (like me) address IT challenges–the costs add up. And it is to this that I want to make my final point.

I began this blog by stating that I didn’t think my father would survive with that survival related to the dawn of the EMR. His was a large primary care practice in a small town. I never knew his cash flow so I don’t know if the federal subsidy would have been enough to get an EMR up and running in his office, let alone how it would have disrupted the office work flow. But most importantly, with all the time consuming documentation requirements, I don’t think he could have continued to see those 40-60 patients a day. Fortunately he retired before all this came about, but I always wonder about current small 1-2 physician practices in those very small towns, away from the “big cities” and their large health care systems, who are trying to make ends meet and take care of their patients while dealing with an EMR. So what would have been the biggest compromise of patient care then, the 5×8 index card or the EMR?

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