As patients, we must be attuned to how the digitization of medical records impacts us.
Copy-and-paste, templates, macros, checked-boxes and other documentation shortcuts can provide valuable efficiency to doctors and nurses alike. But when it comes to patients' medical records, there is a fine line between convenience, comprehensiveness and risk.
A Columbia University study published in 2010 reviewed electronic records from 100 randomly selected patient admissions. The analysis found that between 54 percent and 78 percent of the words used were identical in chart after chart after chart.
Increasingly, as patients' medical records become electronic, they stand to become more important than ever before. They represent a common resource for a broader spectrum of healthcare providers -- heightening the need to ensure that the information captured within them is accurate and complete. And, it is our medical records that represent us and differentiate us as patients -- and as people -- when we cannot: after the exam is over, when a new doctor reviews our health history and in critical scenarios when we can't speak for ourselves.
Around the globe, we face increasingly complex and intertwined diagnoses, treatments and recovery paths. As a result, it is vitally important to capture and preserve the nuances of each patient's care path. The following demonstrates how important this is: Consider two 65-year-old women, each with a broken ankle. Their respective electronic health records (EHRs) would have the same point-and-click boxes checked off by the physician or nurse, providing the following information:
- Time of occurrence: One hour prior to arrival
- Course of pain: Constant
- Location of pain: Left foot
- Location of bleeding: None
- Assessment: Broken Left Foot
While the care scene is set, the complete story is not. What the template point-and-click approach cannot communicate is each woman's unique story:
Woman #1: The patient is a 65-year-old female who presents with a complaint of left foot pain. She woke up this morning and had a donut for breakfast instead of her usual bagel, and while eating breakfast she heard the phone ringing in the upstairs bedroom. She ran upstairs to get it. She felt dizzy and fell down the stairs, injuring her left foot.
Woman #2: The patient is a 65-year-old female who presents with a complaint of left foot pain. She was playing soccer with her grandkids in the backyard and slipped, injuring her left foot.
As it turns out, two seemingly similar injuries may have very different causes. One -- because of an atypical sugar intake -- indicates injury potentially associated with diabetes, while the other illustrates an active woman who appears to have fallen while playing a sport. This means two very different scenarios and two very different future care plans.
In many instances, as part of the implementation of EHRs, doctors have lost the ability to document in the way they prefer and to which they are accustomed -- through speech. Inherently, EHR systems offer no alternative to the keyboard and mouse, but at what cost? Surely electronic records bring tremendous value to healthcare. Their ability to make access to and exchange of information near instantaneous, is invaluable to the delivery of care and to caregiver coordination. But these digital records will ultimately prove to be only as valuable as the information captured within them. Furthermore, it is the information that physicians capture today, that through healthcare information exchange initiatives, will be leveraged to improve care tomorrow. It is information that is too valuable to abbreviate.
According to a study published last year, residents are spending up to twice as much time on documentation as their counterparts did two decades earlier. Isn't technology supposed to add efficiency? Furthermore, 90 percent of 1,000 physicians who were surveyed said they were concerned about usability issues as a leading obstacle to electronic health records. If doctors aren't broadly embracing these systems and the information in them isn't fully chronicling the patient's narrative, we will never achieve the goals we seek for enhanced healthcare. The solution was perhaps best alluded to by Stephen M. Sergay, M.B. B.Ch., Past President of the American Academy of Neurology in 2009:
Humanism needs to be restored to the overwhelming demands of technology, scientific advances and econometrics. I believe that delivery of high quality care begins with the physician-patient encounter, therefore demanding a quality narrative of the history of the main complaint.
If we are to achieve the anticipated success of digitizing patients' medical records, we must enlist technology that enhances care and the physician-patient interaction. These systems should free doctors to do the work for which they are specially trained. They should enable physicians to capture and access more information, not less. Healthcare as an industry may be behind on information system standardization and adoption, but the lives that are represented by that information are too valuable to rush. When it comes to storytelling, it's a fine line between telling too much and not telling enough, but when you're discussing the care of a patient, the absence of a detail could change a life.
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