Episode I: Evolution of Medical Records – A view from the Trench

An account from a Dr’s perspective - Dr. C McClanahan (Forbes 2012 - www.forbes.com/sites/carolynmcclanahan/2012/02/21/the-medical-record-revolution).

The original purpose of the patient chart was to record and document the patient’s medical history. This was for two good reasons; firstly for the purposes of recall and secondly to share medical information with other healthcare professionals who care for the patient. These records or charts are usually completed and updated during the patient engagement, but can often be updated after the patient has finished their episode of care.

With an increase in medical malpractice litigation, the chart evolved to be about “proving the right things were done for the patient”. 

Then medical records evolved again, to document that enough was done to warrant the bill for the patient’s insurance. The more that was documented, the more that could be billed for, resulting in needless investigations or unnecessary referrals – clogging an already busy system.

If you were to liken this to a sporting game then the score line would be Patient/Doctor 2-2 Insurance/Legal. 

However, insurance companies have used the patients’ medical records to determine insurance cover and premiums for other insurance. So if the patient was over-analysed in the treatment phase and/or over-billed in the re-imbursement phase – it may lead to greater likelihoods of claims denial or higher premiums for the patient. The playing field is now moved to look more like Patient/Doctor 2-3 Insurance/Legal. 

Evolving to an electronic medical record does not change the purposes or uses of the data; electronic seeks to make the record better or more efficient to access. However, there are other benefits.

One of those is the research element – it should be faster to track illnesses and analyse how good various treatments for those illnesses are. There are, of course, issues, mostly related to coding (or rather mis-coding) which are linked to over-treatment or over-billing.

Another benefit is in Clinical Decision Support. Rote memorisation is potentially no longer required, there is potentially more time for the patient. There should be faster and better outcomes. Finally, there is the benefit to be gained from knowledge sharing. The British Medical Journal’s Best Practice is a good example.

The score now is potentially Patient/Doctor 5-3 Insurance/Legal but there is still a way to go to get the current 2-3 deficit reversed.

Billy Diggin -  Chief Technical Officer, Sláinte Healthcare

Billy joined Sláinte Healthcare in 2009 as Chief Operating Officer, where he has responsibility for day-to-day technical operations, new product development, and commercial assessment of new products and markets. Billy now holds the position of CTO, bringing over 20 years of experience in product and business development in electronics manufacturing and software automation. Billy was VP Engineering and VP Business Development for Xsil, Director of Software, Pentus Technologies. He has a Bachelor’s and Masters Degrees in Engineering from the University of Limerick, and a first class honours MBA from Smurfit Business School, UCD.