With EHRs, When Seeking Clarity, Begin at the Beginning

People have been so anxious to apply computers to healthcare that they have overlooked Lewis Carroll's sage advice: Begin at the beginning. The problem of losing one's way as a result of beginning in the middle of a problem is not unique to EHRs as we are reminded by Tim O’Reilly, a publisher of computer-related books and a technology pundit.

His recent article “Before Solving a Problem, Make Sure You've Got the Right Problem,” is worth reading because it pinpoints the root cause of the problems that will result from the federal push for EHR. O’Reilly is actually discussing another issue, intellectual property rights, where the government is also trying to meddle legislatively in a “problem” that they have incorrectly defined, do not thoroughly understand, and where intervention may very well do more harm than good.

So, when it comes to the medical record (electronic or otherwise,) what is the right problem? The best way to approach this question is to start at the beginning - define and classify the problem before starting to build.

Let's begin with the word “record.” As a noun, it means "An item of information inscribed onto or into a temporary or permanent physical medium." As a verb, it refers to the act of creating the record. Neither the nature of the information, the medium, nor the means of doing the inscribing is specified. The information could be an audio stream, a picture, a written narrative or discrete data element entered on a form. The medium could be paper, clay tablets, words laser-etched on metal discs, or computer storage of some sort.

The next questions are what to record, for what purpose, for whose consumption, and how long it must be/should be accessible - in short the familiar who, what, why, where, when, how and so what? Why really defines the agenda.

Think about all of the reasons that someone might be prompted to make a record of something related to a patient's health, illnesses or care.

• Billing

• Legal and regulatory concerns and requirements

• C3I (Command, Control, Communications, and Intelligence). Command and control refers to the ability to manage complex sequences of events, including gathering information, marshaling resources, and directing or controlling processes. Communication is often an integral component needed to enable this coordination.

• A lifetime record of a person's health, genetic heritage, inborn conditions, and a catalog of events, either planned or unplanned, that will have an ongoing impact on the person's health and/or any treatment they are offered or to which they are subjected.

• A laboratory notebook (colloq. lab notebook) is a primary record of research. Researchers use a lab notebook to document their hypotheses, experiments, and initial analysis or interpretation of these experiments. The notebook serves as an organizational tool, a memory aid, and can also have a role in protecting any intellectual property that comes from the research. [Wikipedia]

• Making data available for decision support. A working definition has been proposed by Dr. Robert Hayward of the Centre for Health Evidence; "Clinical Decision Support systems link health observations with health knowledge to influence health choices by clinicians for improved healthcare."

• Adding data to a data warehouse. “In computing, a data warehouse is a database used for reporting and analysis.” [Wikipedia] The data that are to be collected and the manner in which they are formatted and organized within the warehouse are determined by the specific reports and/or analysis that are contemplated. Data Warehouses are not intended to serve as an receptacle into which random data can be dumped in the chance that someone might want to use it later.

Each of these requires a more detailed discussion of what it is, how long the recorded information needs to be retained and what value, if any, is added by making the recorded information part of the patient's chart? The next installment will begin that discussion.

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