Evolution of Medical Records: From Hippocrates to Present Clinical Care

1. Lecture #11 INFO 590: Fundamentals of Clinical Care for Health Informaticians The Patient Record kharrazi@iupui.edu http://www.info590.com

2. Introduction and History Present Medical Records Computer-Based Patient Record (CPR) Data Entry Coding and Standardization Representation of Time Structuring the CPR Clinical use of the CPR Lecture in a Nutshell

3. Introduction and History • The traditional paper based patient record used in a clinical setting generally contains the notes of clinicians (alphanumeric data) and other care providers. These notes often are supplemented with data from other sources such as lab or imaging results. • In the fifth century B.C., medical reporting was highly influenced by Hippocrates who set two goals for it: (1) it should accurately reflect the course of disease, (2) it should indicate the possible causes of disease. • Hippocrates used a time oriented style. In Time-Oriented Medical Records, the description mainly reflect the story as it is phrased by the patient. The main intend of physicians at that time was collecting the patient’s history with minimal interference.

4. Introduction and History cont. Description of a disease by Hippocrates 2,600 years ago. The patient history is that of Apollonius.

5. Introduction and History cont. The description starts with the patient’s history prior to his request for medical help: "Apollonius was ailing for a long time without being confined to bed. He had a swollen abdomen, and a continual pain in the region of the liver had been present for a long time; moreover, he became during this period jaundiced and flatulent: his complexion was whitish." Hippocrates proceeds with the reason for seeking medical help: “After dining one day and drinking to excess, Apollonius at first grew rather hot and took to his bed. Having drunk copiously of milk, boiled and raw, both goat’s and sheep’s, and adopting a thoroughly bad regimen, he suffered much therefrom." Reports on the progress of the illness follow from that time onward. They are not provided daily, but are provided only at times when important changes in the symptoms occur. “There were exacerbations of the fever; the bowels passed practically nothing of the food taken, the urine was thin and scanty. ….. About the thirtieth day acute fever; copious thin stools; wandering, cold extremities, speechlessness. Thirty-fourth day: Death.” Description of a disease by Hippocrates 2,600 years ago. The patient history is that of Apollonius.

6. Introduction and History cont. • Until 19th century physicians based their observations on what they could hear, feel and see. In 1816 Laennec invented the stethoscope. The advent of this new technology caused the emphasis of the patient record to expand the scope from the story told by the patient to the findings of the physician and the nurse. • In 1880 the American surgeon William Mayo formed the first group practice which became the well-known Mayo Clinic in Rochester, Minnesota. At the beginning each doctor kept a complete note from each visit but the problem was the separated notes of a given patient between different doctors. • In 1907, the Mayo Clinic adopted one separated file for each patient. This innovation was the origin of the patient-centered medical record.

7. Introduction and History cont. • In 1920 the Mayo Clinic management agreed upon a minimal set of data that all physicians were compelled to record. Most of the Mayo Clinic records were considered Source-Oriented Medical Records. • In 1960s Weed introduced the Problem-Oriented Medical Records which each patient was assigned one or more problems. Notes were recorded per problem according to the SOAP structure, which stands for Subjective (the complaints as phrased by the patient), Objective (the findings of the physicians and nurses), Assessment (the test results and conclusions such as diagnosis) and Plan (the medical plan such as treatment or policy). • The disadvantage of the Problem-Oriented Medical Records is that data associated with more than one problem need to be recorded several times.

8. Introduction and History cont. Time-Oriented Medical Record

9. Introduction and History cont. Source-Oriented Medical Record

10. Introduction and History cont. Problem-Oriented Medical Record

11. Present Medical Records • Pure time-oriented medical records make trend analysis difficult. For example to track the hemoglobin changes over time the physician should go through multiples lab results on separate pages between other notes to find them. • Trend analysis can be facilitated with source-oriented records where the lab tests are separated from the clinical notes. Clinical notes usually apply the problem-oriented records. • A medical record can be used in: Supporting patient care (source for decision making and sharing information), Legal documentation, Supporting research (clinical, epidemiological, quality of care and even drug surveillance), Educating clinicians and Healthcare management and services.

12. Present Medical Records cont. • A fundamental limitation of paper-based records is that they can only contribute passively to the decision making process of the clinician. The record cannot actively draw the care provider’s attention to abnormal laboratory values, contraindications for drugs, or allergies of the patient. • Other disadvantages of paper records are: • The record can be only at one place at a time • The contents are in free text (variable in order, incomplete and ambiguous) • For scientific analysis, the contents need to be transcribed with potential errors • Paper-based notes cannot give rise to active reminders, warnings or advice (not active).

13. Present Medical Records cont. Sample Paper Based Medical Record

14. Computer-Based Patient Record (CPR) • Several elaborate systems developed in the 1970s such as COSTAR, TMR, RMIS, STOR and ELIAS. These systems use so-called encounter forms where part of the patient data such as diagnoses and problems that the patient is known to have is pre-printed. Therefore only basic administrative information appears on the form. Most of the encounter forms have a number of fixed items, which the care provider is expected to fill in (weight, BP, PR, RR, …) • After office hours the contents of the forms are entered into the computer by clerical personnel. Clinicians can consult the patient record on the computer at any time. • Transcription of freehand dictations by clerical staff has the disadvantage that the data are not immediately available and may contain errors as a result of misinterpretations.

15. Computer-Based Patient Record cont. Transcription (either manually or by OCR)

16. Data Entry • Natural Language Processing (NLP) • NLP can be applied to the existing free text. The text must be obtained by Dictaphone or a Speech Recognition system. • The most elementary form of NLP produces an index of the terms used which can be used to retrieve the text. However when the search criterion is for instance cough the result will contain cases in which cough has been positive as well as negative. • Unfortunately narratives often contain ambiguities that can easily be resolved by a human but not by a computer algorithm. • NLP cannot stimulate care providers to be more complete and more explicit in their descriptions.

17. Data Entry cont. • Structured Data Entry (SDE)Entering the data in a structured format (SDE) also decreases the ambiguity of the obtained data. SDE differs significantly different from the present routine of patient data entry. • Forms for Data Entry: In the context of a given medical specialty only a limited number of items needs to be specified that can be combined in limited number of forms. The data entry task is then reduced to filling out these forms. • Form creation depends on the specialty; in broader fields like internal medicine nearly all imaginable findings must be available to the physician. • Hence, the CPR must also support SDE for large medical domains.

18. Data Entry cont. Example of a screen of a SDE system that helps the user to select the symptom or complaint to be described. The list on the left presents complaints of a general nature. The symptom list on the right has a specific focus, depending on a location selected by the user, in this case the chest.

19. Data Entry cont. The screen of a SDE system offers predefined options for description after a symptom has been selected. Here, “cough” can be further specified by direct descriptors and associated symptoms. More detail can be added via the buttons “more” and “additional.”

20. Data Entry cont. Dynamic SDE: When the domain is large and when the findings to be entered are unpredictable, forms ideally should be dynamic, which means that their options should automatically be tailored to the topic of interest. Menu-driven user interfaces are well known but the CPR user may face the problem of not knowing how to navigate through the menus to reach a certain item. Shortcuts can also be used. Interfaces for SDE: A variety of methods have been applied to improve the efficiency of SDE. For example displaying several levels in the menu tree at once can help. Speech recognition can be used in combination with SDE. To make a CPR efficient and attractive for physicians and nurses, it is essential to make optimal use of available interface techniques (Human Computer Interaction).

21. Data Entry cont. User Adaptive SDE: Many clinicians describe their abnormal findings at a level of detail that they consider relevant. Most users develop their own style for history taking and physical examination. In daily practice clinicians follow a certain pattern of actions, and they only go deeper into something when they encounter abnormalities during the first screening. The fairly constant nature of routine history taking and physical examination can be used to make an SDE application more efficient by expanding it with a feature that allows it to ‘learn’ from each user and adapt. For example the SDE application can learn what summarizing items a user uses and which annotations they use to indicate normal statements.

22. Coding and Classification • Large scale projects that involve multiple institutions, even at an international level, not only need structured and unambiguous data but also need semantic exchangeability of data. • Coding systems such as ICD, SNOMED, READ and ICPC are under continuous development in order to supply an internationally accepted vocabulary for the medical domain. • The challenge is to obtain not only structured data but also a mapping of entered data onto these coding systems.

23. Representation of Time • Time plays a very important part in healthcare. The patient’s course of disease unfolds over time, the physician’s insight may evolve over time, and protocol based care involves actions with specific intervals in between. Therefore time stamping is essential. • Time stamps are essential for detecting trends. For example the decrease of WBC in a patient can conclude different results based on the recording times. Time stamps must be recorded in a standardized format in the CPR. • Temporal indications are essential for legal issues. For example a physician may not be held responsible for improper medical action taken on the basis of insight that was available at a later time but that was not available at the time that actions were taken.

24. Structuring the CPR • Events • A patient record describes events as a function of time. Examples of an event are a patient visit, a hospital admission, a surgical operation or the arrival of an X-ray report. • Each event contains different data components (patient history data, lab results, X-ray picture and …) All separate data components require some activity from the healthcare providers. Therefore the data components are called actions. • In short, the events contain one or more actions, and actions may contain different data components. The different data are collected as a function of time during the diagnostic-therapeutic process, which gives a further ordering of the data in a patient record.

25. Structuring the CPR cont. • Relationships • It is important to have insight into how the data in the record are interrelated. These relationships are not self-evident; the temporal order will only tell part of the story. • Even when patient data are not complete the treating clinician is often able to draw correct conclusions from the available patient data which makes extracting the relationships harder. • In a CPR the user should be able to define different problems and to denote why an intervention is done. The links between actions and patient problems reflect the clinician’s insight. For example an ECG was ordered because the patient showed signs of angina pectoris. A SOAP based CPR could be helpful to show the relationships.

26. Structuring the CPR cont. Sample SOAP Note

27. Structuring the CPR cont. A computer-based patient record describes events as a function of time (e.g., a patient visit at time t1 or a hospital admission at time t4). Each event contains different actions (e.g., patient history taking, ordering a laboratory test, prescription of a drug). The actions result in data components (a blood pressure, diagnostic code, ECG, or an X-ray). The CPR should support the definition of links between the different components (indicated by arrows). Actions may be related to one or more problems by defining multiple links. The CPR should also support problem-oriented recording of patient data (green and white shades).

28. Structuring the CPR cont. Example of how clinicians may change their insight regarding a diagnosis. The assignment of an expression of certainty should be expressed with each diagnosis, together with the specification of the time period when the insight applies.

29. Structuring the CPR cont. • Views • Certain data generally occur in every patient record: demographic data, signs and symptoms, medications, diagnostic assessments and treatment plans. • The partitioning of data into categories give structure to a patient record, which can be called the macro level. At the micro level we discern the contents of the categories such as actual complains and findings. • The source-oriented view is in contrast to and, in a way, orthogonal to the problem-oriented view. Source-oriented view is content-independent whereas a problem-oriented view is not. For example in a source oriented view the result of a blood work will always be located in the lab results irrespective of its actual value. In the problem-oriented view the results of a blood work is related to an action.

30. Structuring the CPR cont. • Reliability • As computer-stored patient data are to be used for many purposes and by different healthcare professionals, then the reliability of patient data is of utmost importance. • CPR systems should improve data reliability with validity checks and stimulate completeness during data entry  at data entry the clinician should be encouraged to enter complete data and the system may assist with checking the consistency and the reliability of the data.

31. Clinical Use of the CPR • Despite all of the developments regarding the CPR, it is still only used on a small scale in most settings (world wide). • Apparently most present CPR applications do not yet outweigh the advantages of the paper-based record. • Familiarity with the current routine of using paper based patient records plays an important part. • Portable equipment and wireless networks have had a positive impact on the CPR integration into intensive care units.

32. Clinical Use of the CPR cont. Advantages of Paper-Based and Computer-Based Patient Records

33. Clinical Use of the CPR cont. Assumed advantages and disadvantages of paper records

34. Clinical Use of the CPR cont.

35. Introduction and History Present Medical Records Computer Based Patient Record Data Entry Coding and Standardization Representation of Time Structuring the CPR Clinical use of the CPR Summary