By Ken Price
At the beginning of my Nursing career in 1978, paper medical records were the rule. The only information automation in common use was primarily in non-clinical areas – billing, supply, payroll. The few clinically related applications were in places like the medical laboratory where new information technology was proprietary to the analytic instruments produced by a given vendor.
Direct clinical care was all analog. Clinical data – temperature, blood pressure, all types of measurements were obtained through human observation or devices such as mercury thermometers and blood pressure cuff. At any given patient encounter, data gathered by the clinician might be scribbled on the most readily available surface including clinician’s hand and arms until the information could be documented in the patient’s paper medical record. The documentation was generally narrative with the clinician doing their best to recall the events, observations, and findings relevant to each patient encounter. It should not be a surprise that key pieces of information were often omitted because of faulty recall or interruptions, and documented in a manner that obscured the relationship of one piece of information to another, resulting in an increased likelihood that important parts of the clinical picture were missing – think jigsaw puzzle with pieces missing.
Unsurprisingly, handwritten notes were as laborious to read as they were to write. Having to hand write all clinical notes, coupled with poor penmanship of the writer, and the result was a process that detracted from, as much as supported, quality care. In those first few years of my career, both before and after I entered the Air Force Nurse Corps, one specific element of paper records became a pet peeve of mine and is the single most significant reason I ended up as a nurse working in health care information technology – a nursing specialty now called Nursing Informatics. That element was the documentation of the patient’s allergies, especially medication allergies.
In a paper record, allergies were typically hand written in a box at the bottom of each page of the record, front and back. On admission of a patient, it fell to the nurse to assemble a new record. To save time, admission packs were pre-assembled to include the minimum essential types of forms. Once the nurse had completed the admission assessment, they then needed to document all relevant information in the new record. It is not uncommon for people to have multiple allergies. Let’s say a patient has five allergies and their new medical record pack contained 15 paper elements or pages. Since allergies were documented on both the front and back of each page, there would be 30 times the allergies needed to be transcribed – 5 allergies written on 30 pages equals 150 manual entries the nurse would have to make. The process was not only time consuming but highly prone to errors of omission, transcription, and misinterpretation (that handwriting thing again). Not only that, but each time a new element was added to the record, the same information was handwritten again.
Safe, high quality patient care depends on sharing accurate, timely, and comprehensive patient information. Additionally, the information must be in a form that is widely available to those with a need to know, easily consumable, and preservable. Patient allergy information needs to be shared with pharmacy and food service staff, at a minimum. In the ancient times of the late ‘70s and early ‘80s, this required nursing staff to once again transcribe allergy information to medication and dietary orders. Each transcription was an opportunity for failure. This became my personal goal; to do whatever I was able to accomplish to eliminate such a tedious, high risk problem prone process dependent on human action. There had to be a better way.
In the early ‘80s, I was stationed at Wilford Hall USAF Medical Center, the largest hospital the Air Force operated. Microcomputers were just emerging on the scene and some work centers were beginning to use them for tracking their activity. I was also introduced to mainframe computing. The hospital had just installed a new centralized computer that offered a spacious16 kilobytes of magnetic memory core (if you aren’t familiar with this: https://en.wikipedia.org/wiki/Magnetic-core_memory). The medical systems manager was ahead of his time. He came seeking people from all clinical and clinical support areas with an interest in medical computing to participate in a familiarization program. The goal was to stimulate thinking about the application of computer technology to their area of practice. Coincident with that development, the hospital installed their first electronic monitoring equipment in the intensive care units (ICU), one of which, Pediatric ICU was my duty area. The equipment could monitor heart rate, respiratory rate, and intra-aterial blood pressure. Sounds good, right? Not so much. As there was no central equipment to which the bedside devices could be connected and no Electronic Health Record (EHR) to house and present the data, we had to copy the values from the monitors to paper flow sheets. A start, but not much of an improvement.
In my limited knowledge of computing capabilities at that time, my thinking about how to manage allergy information was at best, rudimentary. Essentially not much more than word processing functions.
Flash forward to now. Allergies and the need to manage as structured data are now one of the key functionalities of EHRs. Allergy related data – allergen (that substance that causes an allergic reaction), type of reaction (hives, anaphylaxis) severity (mild, moderate, life threatening) are now all codable by a number of data sets such as SNOMED, RxNorm, and LOINC to name a few. Once computable, the data can be used to cross reference a drug to other drugs and identify the potential of other drugs to cause the same reaction. The data can be used to initiate alerts should a provider inadvertently prescribe a drug to which the patient is allergic. The same can happen with respect to food allergies. Data can be aggregated to support research – allergic reactions that occur can be documented and shared across the healthcare team, across health care systems, and reported to various monitoring programs such as those managed by the Food and Drug Administration. These capabilities are all extensions provided by automated systems that support improvement in care quality, safety, and cost.
For me, this is a realization of the solution to the pet peeve I had about paper records beginning some 40 years ago. Getting to this point required creativity and intense collaboration between clinicians, developers, requirements analysts, and test engineers assisted by those of us with a foot in both clinical and technical worlds to act as interpreters, go-betweens, and facilitators. Allergy management is just one of the computing capabilities required of even the most rudimentary EHR. Modern EHRs provide substantially more capabilities, but they too are incomplete. Medical computing has the potential to off load the “librarian” functions from the clinician’s cognitive workload through the application of capabilities such as Natural Language Processing, machine learning, and information aggregation from either a single patient’s record or the records of thousands of patients. Genomic medicine, the ability to customize a patient’s care based upon their genetic uniqueness, is wholly dependent upon computational methods combined with a massive store of individual and population health care and genetic information.
Those of you reading this post all have a role in bringing these capabilities to reality. You are, right now, part of a health care revolution and are bringing into existence the tools needed to fix that pet peeve of mine from so long ago. I thank you personally and professionally.
Ken Price is a farm boy from Montana who became a registered nurse, joined the Air Force as a Nurse Corps Officer, and retired 21 years later. He is a husband, proud father of a daughter and son, and doting grandfather of 3 grandchildren. His interest in health care computing coincided with the emergence of the personal computer and grew throughout his health care career. During his Air Force Career, he was the first USAF Nurse to be assigned as a Major Command Medical Systems Officer in the Command Surgeon’s office. He managed an engineering research and design project leading to the development of medical systems specific telecommunications infrastructure design for hospitals, then was the technical project manager for the installation of that design in Air Force Hospitals, and project manager for software development of an Air Force-wide Medical Readiness Decision Support System. Following retirement in 2000, he has been a contractor project and program manager for multiple federal projects. He now works for VetsEZ as a project manager.