For example, to accommodate medical progress at the turn of the twentieth century, the medical records of the NYH were revised. They were now organized around graphs and a table, which left no room for any narrative—merely brief descriptions. House physicians no longer summarized the course of a patient’s hospitalization; they recorded their observations, but not their thinking. Physicians eventually broke free of these constraints. They began writing some interim notes across the columns and demarcating their notes from those of the nurses. Some physicians eventually moved beyond the tables altogether and composed occasional follow-up notes—the first progress notes—on the form that was originally used only for the initial physical examination. By 1922, either within or outside of columns, physicians were beginning to offer diagnostic speculations. The discharge summary evolved from words to sentences and was written first across the page, then on the back of the tables, and finally on a sheet of its own. Formal, typed discharge summaries would soon follow. Physicians had started to document their findings and opinions despite the forms.
Explore this issueMay 2012
Also by this Author
The Early Years of the EMR
For most of my years in practice, I have used an electronic record. Our hospital first proposed that we begin using an EMR in 1989 as a way to document our division’s expertise in patient care. This served us well whenever the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) arrived for their periodic reviews.
I recall the communal hand wringing when we realized that the paper charts containing the rest of our patients’ records would not be traveling with them to their clinic visits. This created some interesting challenges when trying to assimilate outside lab results and consult visits into the record, since scanning technology had not yet become commercially available. Somehow, we managed to deal with this issue.
More daunting was the high cost of medical transcription. A two-page typed consultation cost about $8.00, while a follow-up note charge might be around $3.50. Multiply those numbers by 25,000 visits per year and the results were eye popping. Some members of our division decided to work with an upstart dictation service company. They promised great results at half the cost. What we got were half the results at the same cost but with some laughs thrown in. Most of their typographical errors were minor irritants, an errant “s” here or there. There were countless in-note sex changes and there was a generous use of phonetic spelling. My dear 90-year-old patient became an adolescent 19-year-old girl with “Polly-myalgia room attica”. Then there was my patient with a pigmented villonodular synovitis of the knee that was transcribed as “pelvic inflammatory sinusitis.” Now talk about a fascinating juxtaposition of human anatomy! In his book, America, the comedian Jon Stewart quips that the Massachusetts legislature ratified everything in John Adams’ 1780 Massachusetts Constitution, “except the letter ‘R’.” This may explain how that rare mimic of central nervous system vasculitis became typed as “moyer-moyer” in someone’s record. One of the many hazards of living in Boston!
Some Novel Future Uses of the EMR
Despite these quirks, I would never trade the EMR for pen and paper. Yes, there was a time when some medical notes were elegant missives full of flowing prose that described lengthy hospitalizations. The penmanship was superb, cursive letters carefully constructed using a fountain pen. After all, the writers had plenty of time. They were not likely to be interrupted by the hospital paging system, beepers, or text messages. The Current Procedural Terminology (CPT) codes, which dictate the requirements for the content of notes, had not yet been created.