So what exactly do we want a patient-centered medical record to look like?
What is the point of a patient’s medical record? Historically it has served many functions. Perhaps the time has come to reassess what it needs to be, what it can and should be.
If a healthcare provider from one or two generations ago were to look into a patient’s chart today, would they recognize what they saw? Would they know where to find information they needed to take care of the patient? Would it look anything like the old pen-and-paper chart we used to keep? And would they think that what we have now is better?
Our charts used to be thick folders full of different kinds and colors of paper: lined progress note paper on which we had to write the patient’s name and medical record number, a yellow page with a problem list, a pink page with surgeries, a purple page with allergies, a green page with medications.
Thick reams of old notes piled one on top of the other documenting years of a patient’s care. Handwritten notes (“chicken-scratching”!) with at most a small diagram indicating where on the leg the cellulitis was, for instance, or where we heard the murmur.
Sure, a lot of the same fields would be there: a brief description of the patient’s complaints from that day (now labeled HPI), some sketchy but possibly relevant details of past medical history (copied from the inside cover of the chart), a review of systems. But, although many of the same sections and abbreviations exist today (some without any clear benefit), in fact much of the chart would look foreign to a healthcare provider of another generation.
And thick and unwieldy as old paper charts may have been, our EHR has created a charting monster.
It is less about creating a true repository of useful information about a patient’s health than a regulatory and CYA document that sometimes makes it impossible to discern the reality of what took place.
We need medicolegal and compliance documentation, but the core kernel of medical truth is too often missing. Lost is the vital ability of the chart to help us care for people, and communicate with each other.
I have seen massive notes from subspecialists when the patient assures me the doctor never actually examined them or even talked to them.
I have seen patients come in with medication lists that show that doctors have dutifully clicked that they “reviewed” medications, when shockingly the list is years out of date and often has multiple copies of multiple medicines.
And “cut-and-paste” and “copy-forward” are two electronic hells into which we all have fallen more than once.
I’m not saying I want to throw out the baby with the bathwater. Much of the EHR has been revolutionary and even life-saving. Electronic prescribing and drug-interaction filters have no doubt paid off the cost of the EHR many times over. Not to mention avoiding the issue with doctors’ handwriting. Not to mention avoiding the issue of not being able to find the chart in the first place.
There has been a movement around to allow patients greater access to their charts, even seeing the office notes from each visit and letting them provide feedback. Although some feel this would keep providers more focused and honest in their charting, this puts the emphasis in the wrong place.
A more patient-centered focus might be to have the central parts of a patient’s health history exist as a permanent, mobile, electronic core, that every provider gets to interact with and respond to.
This record would move with the patient from office visit to office visit, from the clinic to the community, becoming richer as each new provider interacted and contributed.
Gone would be the need for patients to fill out a new paper questionnaire listing their whole health history at every new office they come to, and gone the need for us providers to dutifully re-enter it all in a new chart.
I know this has been one of the main goals of HIPAA, but it seems a fitting time for us as healthcare providers to seize the reins and help make this happen. Our new EHRs give us some of these abilities, but we — and EHR makers — have just barely tapped in to this potential.
Getting all the players who use the EHR to think this way and change how we chart is going to be one of the great challenges as we move forward with making our system more patient-centered. The hope is that it will make our lives easier and our patient’s lives healthier.
Fred N. Pelzman is associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.
