In the beginning there was memory. The physician’s memory was the original repository of the patient medical record. Memory was supplemented by handwritten notes on papyri in ancient Egypt and Babylon and on paper from medieval times to the 20th century. With the advent of recording devices in the 20th century, handwritten notes gave way to the infinitely more time effective practice of dictating patient notes into a recorder which were then transcribed into a typewritten or word processed document. Of course, that practice introduced an extraneous third party into the medical record keeping process: the transcriptionist with the attendant additional expense to the physician and loss of privacy for the patient.

At the current time, 21st Century technology offers physicians and health care providers a medical record paradigm that will not only vastly upgrade the process of producing, maintaining and safeguarding medical records but will, in a direct and fundamental way, actually improve the quality of medical care. The technology is Electronic Medical Records (EMRs). EMRs produce the most accurate and complete patient health record possible to date and help physicians practice better medicine as well. EMR technology is available in a plethora of shapes and sizes with a great variety of possible features. The technology can change the way you interact with your patients, from before they make their first appointment to after they’ve left your office, and have questions about their visit in your office.

As a practicing physician you are aware of the repetitive nature of some aspects of your practice, specifically with regard to patient diagnosis. It is very likely that you and/or your staff have asked the same or at least very similar questions to each of the thousands of patients you have treated. Unless you are practicing in a tertiary referral center, and never see the same condition twice, the patient answers likewise tend to be repetitive. Similarly, physical examination findings fit into certain categories that are seen over and over again. For this reason, most of the current high-end Electronic Medical Record products very capably utilize ‘pick lists’ or ‘click and point’ methodology to complete large portions of the patient medical record.

These point and click systems are particularly adept at documenting, for instance, allergies to medications, medications that are currently being taken, past medical history, family history, social history, and major portions of the physical exam. This is the case because of the narrow range of options which are available as patient responses. For instance, your patient either smokes or doesn’t smoke. And if he/she smokes, it is probably 1 ppd, or 2 ppd, or some other value that can reasonably easily be foreseen by the experts who have designed the point and click system for your office.

However, the historical portion of the patient medical record typically has a great deal of information that cannot be easily foreseen by the developers of the point and click templates. For instance, as an Orthopedic Surgeon, my patients frequently find themselves in automobile accidents. It is not likely that the author of whichever EMR may find its way into my office has contemplated the various street names and intersections in my community. Therefore, in a typical point and click system, there will be a scarcity of relevant information concerning the specifics of the accident. And I find that these specifics are important for a wide variety of reasons, not least of which is that they remind me of the particulars regarding this patient when they return to the office. Utilizing templates for the historical portion of the report, while feasible, tends to produce extraordinarily repetitive reports, each of which sounds not only vaguely similar to the previous patients, but in many cases essentially identical to other patients. This certainly makes it difficult to recall the characteristics of this particular patient.

One of the advantages of an EMR is that it allows physicians, hospitals, insurance companies, pharmaceutical companies, medical societies, and other parties entitled to view the patient data for legitimate, permissible purposes, to do so. Legitimate, permissible purposes include coordinating patient treatment, accessing diagnostic procedures and results, preventing adverse drug reactions, and ensuring medical practice within clinical practice guidelines. One particularly high priority purpose from the physician’s standpoint is that the data be accessed by third party payors to streamline reimbursement for services.

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