Wednesday, January 5, 2011

That Which We Call a Rose

What’s in a name? Sometimes nothing much. Sometimes a shift in paradigm.

The Medical Record in its current format was created over a century ago by Dr. Henry Stanley Plummer at the Mayo Clinic. When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine naturally named the new invention Computer-based Patient Record System (CPRS). The Medical Records Institute chose the term Electronic Patient Record (EPR). Somewhere along the line the “patient” got dropped from the concept and the software used to compose and store medical records became known as Electronic Medical Record and the name EMR stuck.

As the EMR software evolved and started exhibiting rudimentary information exchange abilities and some semblance of “intelligence”, it was felt that a name change was in order. To differentiate the newer and smarter software from the original EMR, the term Electronic Health Record (EHR) was introduced and is now enthusiastically supported by the Federal Government. The term EHR is used in acts of Congress, rule makings from CMS and ONC and Presidential speeches. Since EMR has been around for quite some time, most industry veterans, as well as most doctors, are a bit confused about the new terminology. Is it EMR or is it EHR? Is it just semantics? Would an EMR by any other name smell as sweet (bitter)?

In a recent ONC blog, Peter Garrett and Joshua Seidman argue that there is a significant difference between EMR and EHR. The former is just “a digital version of the paper charts” and “not much better than a paper record”, while the latter is “designed to be accessed by all people involved in the patients care”, including patients, and generally “represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual”. This dramatic difference stems from replacing the word “Medical”, which implies disease, with the word “Health” which is “the general condition of the body”. Note that the word “Patient” is still absent. However, Health is supposedly from cradle to grave, while Medical is episodic in nature. Since, no matter what you call it, clinicians are the primary users of this software, would we say that doctors provide Medical Care or Health Care?

When we say that cost of Health Care is sky-rocketing, we don’t usually include costs for clean air, clean water, car seatbelts and gym memberships, and although we all know that an apple a day keeps the doctor away, the cost of apples is not included in our Health Care expenditures. To be sure, Medicine, “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease”, does include costs for direct prevention of specific diseases (immunizations) and efforts for early diagnosis of others (screenings). Historically, doctors, nurses and their less formally educated predecessors have been tending to the very sick. It is with this goal in mind that Dr. Plummer’s collaborative Medical record was created, and it is for this purpose that the American Academy of Pediatrics advocated for a Medical home for sick children, and it is Medical care for the sick which the EMR attempted to facilitate, one patient at a time. The EHR represents quite a different philosophy and places new and expanded responsibilities on the Medical profession.

The EHR is intended to serve the healthy as well as the sick, and the President’s vision is that every American should have one, whether that particular American is healthy or not. The ONC vision, shared by many innovators in the field, is that “EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care”. That broader view will presumably include lifestyle habits, diet and exercise and everything one may wish to record which pertains to one’s general health status. If and when a person becomes ill and is transformed into a patient, the various clinicians and care providers will contribute their documentation to the EHR, and since EHRs are easily shareable, all Medical care will be coordinated through the EHR and collaboration will flourish, as it should. This sounds almost exactly the same as what a Personal Health Record (PHR) is supposed to be. Is an EHR really a PHR?

No. EHRs include one feature that is not possible in a PHR: the ability to aggregate individual patients into populations. When physicians write introspectively about their work, you usually find stories about this or that particular patient, pondering whether they did too much for the 90-year-old Alzheimer’s victim, or too little for the misdiagnosed 40-year-old ovarian cancer patient. They talk about emotions, or lack thereof, about small victories and exasperatingly “non-compliant” middle aged executives who should know better. Each story has a patient with a name, physical details and most often character description. For those inclined to self-assessment, the day-in and day-out tally of these personal episodes is the decisive yardstick. When people recommend a doctor to a friend, they usually talk about “nobody could figure out what was wrong with Katie; he took one look at her and knew right away” or “you can get in today or tomorrow and she is so nice and patient ; always takes my phone calls and you know I can be a pain (giggle)” or “when Adam had that knee problem, he fixed it like magic and he did surgery on cousin Joe’s shoulder; as good as new, and I think he takes care of the Cardinals too; he is definitely the best in town”.

This unscientific, anecdotal method of both performing and assessing one’s work will be replaced by the broader view of EHR enabled population indicators and considerations. Instead of dealing with Mr. Wilson’s gout and Mrs. Wilson’s incontinence, you are now the keeper of the Health of Populations. The EHR can tell you that half of your under 40 patients are obese and doing absolutely nothing about it. You, or your team, will need to intervene because an ounce of prevention today will lead to healthier lives for this population, and lower costs for society. While managing Mrs. Wilson’s neuropathy is important (especially to Mrs. Wilson), having your population of 300 diabetics controlled within acceptable cost effective parameters will become the main focus of your practice. EHRs will provide you with the intelligence (information) to manage your numbers and with ongoing measurements to assess your performance against goals, and EHRs will continuously collect data for ground-breaking research and more effective recommendations.

EHRs, as imperfect, ineffective and downright primitive, as they are today may be our first glimpse of a future where curing or treating disease is largely a thing of the past. If populations are proactively managed and everybody gets their shots and recommended genetic therapy, or whatever they will come up with next, Medical care will be limited to trauma and exotic ailments that have not been researched just yet. While our generation will not be crossing the River into the Promised Land of perpetual Health, it is up to us to manage this transition so human dignity is preserved and collateral damage is minimized in the process of industrializing medicine, a process which starts with changing the M in EMR to the H in EHR.


  1. A Little History,

    As little as a hundred years ago, detailed medical records were likely to have been compiled by medical researchers such as Charcot and Hughlings-Jackson. The medical record was an “aide memoire” for detecting changes in patients’ conditions over time, solely for the benefit of the physician in treating the patient. As health care became more institutionalized, medical records became a communications device among health care providers. A centralized record, theoretically, allowed all to know what each was doing.

    The ideal was that if the doctor were unable to care for the patient, another physician could stand in his or her shoes and assume the patient’s care.

    More recently, the traditional paper SOAP format of medical charting was developed by Dr. Lawrence Weed in 1968. Formally, it is known as the Problem Orientated Medical Record [POMR]. However, the concept was updated about 20 years ago by adding the extension SOAP[IER], which may work a bit better:

    I = Intervention
    E = Evaluation
    R = Revision

    Of course, nurses know this, but doctors still may not. Or; they know but do not execute – a much graver offense.


    Dr. David Edward Marcinko MBA CMP™

  2. Margalit:

    While I appreciate your insights into EHR, your last paragraph in this post displays a notable degree of utopianism. As a family physician with some 30 years experience I continue to be humbled by how little we truly understand about health and disease. I doubt any of us have truly caught a "glimpse of a future where curing or treating disease is largely a thing of the past."

  3. Dr. Anonymous,
    This is indeed utopia, or optimistic science fiction, if you will, but why would it not be possible, in a few centuries, or so, that poverty would be all but non-existent, and most disease would be understood and resolved?
    Extrapolating the rate of innovation and scientific discovery for the last couple of centuries into the future, and assuming humanity does not blow itself up into oblivion, all sorts of things are possible... maybe... or maybe not... :-)

  4. I loved how technology had made such crucial improvements in Medical records. I think doctors and hospitals seem to profit even more than the patients themselves. Just another way modern technology is improving our lives.

  5. what cute cards! and i've been playing christmas music since halloween, it's so much fun to get in the spirit.logo design