Friday, March 19, 2010

A Century of Medical Records

(HIT Lessons from History)

The Nineteen Hundreds

In 1901 Dr. Henry Stanley Plummer, a very young "techie doc" joined the Mayo Clinic. By all accounts Dr. Plummer had both the peculiarities and the single mindedness of true genius. He was, of course an excellent physician, but his largest contribution to modern medicine was the Medical Record.
In 1907 Dr. Plummer and his assistants deployed a novel way of keeping patient records. Up to that point patient records were kept in ledgers. The multiple offices at Mayo each had its own ledger. Once the initial visit was entered in a ledger, all following visits and procedures were added to that page, sometimes in crowded text on the margins. One patient could have entries scattered across a multitude of ledgers. Dr. Plummer introduced a centralized medical record consisting of a big envelope where all doctors would aggregate all the information regarding a particular patient. Each patient was assigned a unique identifier and his/her own dossier of clinical documents. The medical record would follow the patient everywhere at Mayo and all physicians would have access to all records.
Of course, Mayo was an integrated delivery system, bringing together specialists and surgeons and primary care physicians, all working together for the benefit of the patient. The multi-specialty private group was Drs. Will and Charlie Mayo's contribution to the changing face of modern medicine.
But Dr. Plummer did not stop at creating the patient centric comprehensive medical record. After tinkering with a complex system of cables and pulleys, Dr. Plummer came up with a pneumatic system of tubes and conveyors to rush patient records from one office to another. He also invented a communication system between physicians in exam rooms based on the telephone system and a telegraph ticker.

Dr. Plummer implemented Will & Charlie Mayo's vision of clinical collaboration for the benefit of the patient, using the latest technologies available during his time.

The 21st Century

One cannot but feel humbled when exploring the early history of Mayo, and Dr. Plummer in particular, because one hundred years later, all of us in Health Information Technology are still trying to implement Dr. Plummer's original innovation.
Times have changed and we now have computers and Internet and iPhones on 3G networks. It seems we have all the tools needed to create a collaborative comprehensive patient centered record system, so why don't we have one?

Although Dr. Plummer's patient record has changed very little over the last century, the practice of medicine has seen significant changes. The integrated multi-specialty Mayo model has gained some support, but most medical care in the US is not administered in integrated settings. Hospitals today are much different than the original St. Mary's hospital at Mayo and most are profit centers. And then there is health insurance, which brought concerns of privacy and injected financial considerations into every exam room across the country. Pharmaceutical companies, device manufacturers and health related consumer marketing have acquired immense power over the practice of medicine.
Dr. Plummer's patient record morphed from a tool to benefit patient care, into a legal document and mostly a financial asset.

Legal documents and financial assets are not readily shared. Hospitals are afraid of competition and so are their large firms of IT vendors. Independent physicians are afraid of government, lawyers and insurers scrutiny. Patients are afraid of loss of privacy translating into loss of insurance and even loss of employment. On the other side of the chasm, pharma companies are itching to get their hands on "the data" and the direct marketing channel. Insurers are looking forward to even more details to help with risk assessment. And CEOs of every kind of IT company are looking to "monetize" whatever treasures of "data" they can amass.

It is interesting to notice that in closed autonomous environments, where the legal-financial considerations do not exist, like the VA or Kaiser Permanente, patient records are untethered and collaboratively shared by all involved.

Today we are in the midst of a major HIT push, and maybe on the cusp of health insurance reform, and the conversation revolves around enabling physicians to share information. In other words, we are trying to establish a national system of pneumatic tubes, pulleys and conveyor belts for medical records. The interesting part is that we already know how to do that. The Internet moves terabytes of information at any given moment from one end of the Globe to another. We have the means to implement Dr. Plummer's communication system, and we have the framework to enable collaboration, but we are not using any of this tremendous infrastructure. Instead we are embroiled in lengthy debates on the so called Meaningful Use - a laundry list of minute details that need to be recorded and reported to Government agencies.

I wonder if Dr. Plummer's system would have been equally successful and resilient, if he insisted that every patient record, moving through his pneumatic tubes, had to include a smoking status exactly stating "current smoker, never smoked or former smoker". And I wonder if his system would have ever taken off if he started by requiring that a special subset of the medical record should go to the administration office first. And I wonder why Dr. Plummer never referred to patient records as "data".

We may have Dr. Plummer's plumbing in place, but what we lost is Dr. Will Mayo's belief that "The best interest of the patient is the only interest to be considered...".


  1. I came here from your comment Dr. Kibbe's "Health Care Blog" post, and must say I quite agree with your post. I'm a firm believer that there is nothing new under the sun, that technology is a tool we use to improve human systems that predate all tools, and that we must understand where we have been to move forward. Too many times we try to reinvent the wheel, only to fall into the same ruts that those who came before us did.

    I appreciate your consistent, appropriate commenting over at the Health Care Blog, and I've added you to my growing number of RSS subscriptions. Keep up the good work.

  2. Nice post.I agreee with you that We may have Dr. Plummer's plumbing in place, but what we lost is Dr. Will Mayo's belief that "The best interest of the patient is the only interest to be considered...Very well said