Many people think that paper medical charts are hopelessly archaic. The sooner they are all scanned and shredded the better off we will all be. There is nothing worth saving from such primitive systems… or is there? As with any legacy system, is there something we can gain from studying it? If we shred our old paper charts without understanding their evolution and design will we struggle to relearn lessons in designing their electronic replacements? After all printed medical records have existed and evolved for what? Decades, a hundred years, a few centuries…?
How about 4,000 years. The History of Medical Libraries from 2000 B.C. to 1900 A.D, by Kathleen P. Birchette is a fun read describing the history of medical information. Some of the oldest human records ever discovered are of medical descriptions on clay tablets and those records were combined and organized to form a major portion of the earliest known libraries. The people who managed these collections were held in high esteem and received impressive titles such as, “The Scribe of the Double House of Life” or “Keeper of the Sacred Books.” To match their impressive titles they delivered impressive results. With nothing resembling what we would call “technology” they created information systems that demonstrate a sophisticated organizational structure. From Birchette’s article:
“The material was well organized and shelved in systematic rows on the wall in earthen jars according to subject. On the walls were placed lists of the works found in each room. Each tablet, in turn, had an identification tag, which indicated the jar, shelf, and room in which it belonged. A form of catalog or descriptive bibliography was used in conjunction with the identification tags.”
To the list of the world’s oldest professions we can add the medical librarian. From the moment humans started recording information they started organizing it and medical information was high on the list of that worthy of preservation and access. Now, let’s fast forward back to the present. Who developed, designed and managed our soon to be extinct paper charts? The answer is the same – specially trained medical librarians. So, for a run of 4,000 years library and information science professionals have managed the structure of our medical information.
Lets look at paper charts a little more closely. Like the ancient clay storage jars, paper charts were designed to take full advantage of their medium and demonstrated a high level of structure and organization toward supporting myriad search and retrieval tasks required in giving care. Using colored tabs, the chart is divided into sections representing clinical categories. Within each section the documents are arranged in chronological order. Documents with the most important and/or frequently required information use color-coding and edge formatting to facilitate quick identification and retrieval. Though perhaps not by design, the thickness of a chart or chart section can quickly communicate whether a patient has little to no history or has a very complex and difficult history. With a paper chart one can easily flip rapidly between multiple documents to compare information.
By contrast, the contemporary electronic medical record (EMR) mimics the paper chart, but fails to take full advantage of the new medium. Those who develop the EMR are skilled developers, clinicians or both, but the role of the information and library science professional has been limited. This is unfortunate since it is the information scientist who has expertise in organizing complex information so that people can find the information they need, whatever the technology. For example, the EMR has tabs just like a paper chart, but they were copied in a very superficial way. It seems there was little study of the information tasks performed during care and/or an exploration of the potential of the new electronic medium to support those tasks. Paper tabs fully utilized characteristics of their medium; electronic tabs do not. While html hyperlinks have indicated a status of “visited” for almost 20 years (blue vs purple), EMR tabs rarely provide something as simple and useful. Electronic tabs could include simple visual indicators to represent, “You have/have not reviewed this section,” but this could be taken even further to indicate, “There are abnormal results in this section,” or “This section has new information since the last time you accessed it.”
Here at CBMi we are contributing to the demise of the paper chart, but instead of dismissing it we rely on it as a source of ideas and design. For example, in developing a clinical decision support (CDS) system for premature infants we discovered that in managing patients who require a very expensive medication (Synagis) to prevent serious respiratory infections (RSV), the EMR provides no way to manage the complex insurance submission, dose scheduling and tracking processes involved. With no other option our nurses go back to what they know and… you guessed it, they create paper charts. We studied how our nurses assemble and use their ad hoc charts and designed an electronic system that captures the key organizational aspects of their paper based system, but applies advantages of technology in performing many analytical tasks including a chart review, projecting a patient’s weight, dose scheduling and more. We quickly discovered the same techniques could be reused in redesigning the EMR to help nurses coordinate care for other complex patients.
Pediatricians and parents have used paper growth charts for decades. Our EMR includes over 40 different growth charts in an electronic format, but does little to apply the power of technology to help the clinician assess growth (let alone select the right chart). Growth is critical in managing the care of premature infants, so our new system augments the growth chart with calculations and data displays that reveal trends and other detailed information that is difficult to discern from simply viewing the graph. The same designs and even the same programming logic is being reused in another project involving growth, a system to help diagnose and treat children of short stature.
There are paper artifacts outside the chart that can generate new ideas too. The American Academy of Pediatrics Bright Futures project created a “periodicity schedule”, or a timeline of every medical milestone from birth to age twenty-one. Our clinicians give this resource rave reviews and it gave us ideas for managing the care of premature infants. Premature infants are defined by both their chronological age (how long they have been alive) and their corrected age (which accounts for their prematurity). For example, if a child is born 2 months premature, when they are 6 months old (their chronological age), they are to be considered as a 4 month old (corrected age) in terms of their development. Though it seems like simple math, this can lead to a lot of confusion. For example, if a lead screening is recommended at 6 months old, for a preemie should this be done at 6 months chronological or 6 months corrected? How about a blood pressure screening recommended at 9 months? Add immunizations and another two dozen aged-based milestones and it gets very confusing, even for highly intelligent and experienced clinicians.
To help our clinicians manage all this, we were influenced by the Bright Futures design and are developing an electronic timeline that automatically adjusts for the patients prematurity and plots each milestone appropriately. Unlike the paper version the electronic version can indicate whether an item was performed, missed or has an abnormal result. All together this does something the EMR rarely does by presenting the patient’s medical history in a easily digested overview format rich with important information about their past, present and potential future. Like the thick paper chart described above, a timeline with many overdue and abnormal indicators instantly identifies a patient with serious issues. We didn’t stop there. By making every item in the timeline a link to the source order or note within the EMR, we created what is essentially a new chart navigator, but instead of navigation based on the information structure of the EMR (defined by tabs, menus…) the new navigator is based on the actual “information architecture” of the patient.
There are many other examples that could be included here, but perhaps that’s the point. If you are working with a new electronic medical record system, take the time to really study the old paper system. It may be primitive, bulky, hard to read and present barriers to efficiency, but it holds keys to understanding how clinicians work with patient information; in the past, present and the future. Whether your organization has an EMR or not, look around for paper artifacts that people value and use. They almost always represent opportunities to apply information technology in new (and not so new) ways.
Who knows, if you can emulate the ancient Babylonians or Assyrians and create something that takes full advantage of contemporary technology you could earn a fancy title such as the Scribe of the Double House of Life, Keeper of the Sacred Books, Lady of Letters, Mistress of the House of Books, or at the very least be invited to join the Learned Men (and Women) of the Magic Library.