Episode II: Evolution of Medical Records – A Systems Perspective.

This episode examines the evolution of the medium and the format of medical records – from an Engineering (rather than Scientific) point of view.

The Medical Chart originates on a paper medium (and still does today in so many situations). The patient-doctor activity, recorded on paper, is in an Analogue format. Words and drawings are captured with ink, not restricted to anywhere in particular on the pages. While we can easily write and observe the scribbles, it requires highly advanced pattern recognition (i.e. the human visual cortex, etc) to make sense of it all. People keep getting sick, so doctors keep writing on more and more paper, and all this paper needs to be stored somewhere. The individual paper forms are indexed in the patient’s charts/folder and all these are stored in medical records rooms (or often facilities). We need a cataloguing mechanism (similar to a library) to locate the chart in the storage facility and when the chart is not in storage, we need to track its location in the hospital (i.e. who has it). By the way, many medical records managers will tell you that patient charts are never lost, the charts are temporarily mislaid – sometimes conveniently! This demonstrates the portability, and the occasional elusiveness, of the paper medical chart.

Microfiche, commercialised by Eastman Kodak in the 20th century, was adopted as a means to preserve printed/paper documents as well as reducing the storage space requirements. Many hospitals archived their medical records into this film medium, however the format remains analogue (so we can’t dismiss our visual cortex just yet). Of course, a specific conversion process was required, where documents are imaged, and exposed to a film that is subsequently developed. The advantage gained from saving storage space was counteracted by the disadvantage of the need for magnification. As the human eye does not have a zoom function, we needed to invent and use micro-fiche readers. These readers are as portable as a brick and about as user friendly. Naturally, the conversion to microfiche is a one way process. It would be difficult for a clinician to add additional notes to a film, so microfiche was typically only used for archive charts and not “live” ones. Digital Scanning, invented in 1957, was seen as a means to migrate the medical record into the digital age. While the format has now changed to digital, that’s a technicality, as it is just a sampling of the original analogue format (either from paper or film). As with microfiche, there is still a conversion process that requires scanning equipment. The bigger change was with the medium – now represented as a digital image, and brought with it a whole new set of storage and viewing requirements – a.k.a the computer. With the introduction of the computer, we need an electronic patient index to find the right record for the right patient quickly. Now, the big advantage is that the patient medical record can be omni-available – at least to the extent that it can be, given the limitations on infrastructure and computer screens. It could certainly be viewed in two or more different locations by two or more interested parties. The elephant in the room; in the vast majority of cases only archived charts are scanned and made available. It would indeed be a rare occurrence that the end of bed medical chart for a patient currently in the hospital to be scanned – as with microfiche, scanning is a one-way process – no updates can be made after scanning. So a large disadvantage of scanning is that its output always arrives late to the party. Perhaps this derogates the scanned archive to the research and historical (medico-legal) pile, rendering it entirely useless for day to day patient medical reference.

Now that we are in an electronic era (where every smart phone is a digital scanner!), we have the luxury that we can attain a truly digital format, on a computing medium. That computing medium is becoming ever more portable and mobile, and truly omni-available and omni-accessible. Moreover, while we can easily attain digital data, e.g. free flowing word documents, in reality we are striving for structured/sematic data, e.g. XML documents. This feeds and drives those big data opportunities. Without this sematic electronic information capture, big data would be moot data. Of course, we have now significantly increased our dependencies on computing infrastructures, e.g. Cloud, data centres, WiFi, BYOD, Integration, Security, Data Protection, etc. as well as electronic medical records systems, end-user coercion (training), 24/7/365 support, and so on. Maybe paper was not so bad after all?

In reality, hospitals have a hybrid of 2 or more of these media and formats. This stretches the infrastructure requirements that the hospital must provision for the patient paper-film-image-electronic medical record. Two to four different systems and processes need to be in place. This multitude of systems brings another problem. We run the risk of increasing the noise and drowning out the signal for the end-user clinicians. The data and information is disjointed and mismatched and it can be hard to find the truth. In one hospital, data from the EMR is viewed on screen. Some print the report and place it in the paper chart. Other clinicians write additional notes on their print outs and placed in the chart. This simple example highlights that the source of truth can be blurred, resulting in increased risk to the patient. Of course, the solution is simple. Get everyone to switch back to paper!

Billy Diggin - Chief Technical Officer, Sláinte Healthcare

Billy joined Sláinte Healthcare in 2009 as Chief Operating Officer, where he has responsibility for day-to-day technical operations, new product development, and commercial assessment of new products and markets. Billy now holds the position of CTO, bringing over 20 years of experience in product and business development in electronics manufacturing and software automation. Billy was VP Engineering and VP Business Development for Xsil, Director of Software, Pentus Technologies. He has a Bachelor’s and Masters Degrees in Engineering from the University of Limerick, and a first class honours MBA from Smurfit Business School, UCD.

Vitro is an Electronic Patient Chart that replicates your current paper documents and their clinical workflow, by either replacing or integrating with your existing system to provide a complete electronic medical record. Vitro captures complex clinical data & allows the capture of clinician-patient activities in an efficient & paperless environment, thus allowing healthcare providers to extract and analyse data, reduce costs, improve clinical decision support and ultimately improve patient care & outcomes.

Read more: www.slaintehealthcare.com/products-services/vitro-paperless-hospital