Gettysburg Medical News
by Phillip Hoffsten
 22 November 2006

The Evolution of Electronic Medical Records

            This column is about developments in medical records and how we maintain them.  When I started medical school a long time ago, I sat with a pen and a piece of paper and wrote down the medical history in my own handwriting.  For medical students seeing one patient per day in great detail, this is what there was.  My handwriting may or may not have been adequate.

In 1965, interns and residents and fellows in training still used pen and paper to record their notes.  A few individuals whose handwriting was horrible got an offer they couldn't refuse and were forced to learn how to type.  You might imagine this was tedious and time consuming.  So when physicians finished training and went into private practice, their office notes were short and often illegible because the physician thought he/she was the only one who would ever read them.

Specialists and doctors who received referrals from other doctors obviously needed to have legible office notes and letters sent to their referring physicians.  These letters were often several pages long and most physicians did not have the typing facility to do these themselves.  Thus, was born the Dictaphone so the person could dictate into a microphone and a secretary would type the dictated notes later.  Obviously, this increased expense because there was equipment and an additional salary involved.  Recently at our clinic, there were eight transcriptionists solely devoted to typing the doctor's notes.

Twenty years ago the idea that the spoken word could be recognized by a computer and transcribed directly into text began to develop.  Over this time computers have gotten faster and technology improved. At this point, I am now sitting in Mexico on vacation dictating this column for practice using the dictating program.  The text appears on the screen as I speak.  To be sure, there are no “uh’s” or “ah’s” as the computer will try to transcribe every sound that I make.  Thus I must speak very distinctly although in my natural speed, tone, and inflections. The more I use this program the better it will learn what I am saying.

Once I am through transcribing this column I will save it in the computer.  From here in Mexico I will access the Internet and transmit the column back to the Gettysburg Hospital.  From there the column will be sent to several different newspapers in Central South Dakota to be published.

All of this and I didn't have to have a piece of paper or pencil.  I can transmit information over thousands of miles instantly.  I have planned for this day for the last several years.  Now I can dictate a column using the Dragon-9 transcription program and send it over the Internet.

The same technology using the Dragon-9 is also available for dictating medical records into an electronic medical record system.  The idea that medical records would one day become paperless is within reach.  After seeing the patient I can pick up this microphone and dictate directly into the patient's medical record with a transcription appearing before me as I speak.  Corrections can be made on the spot.  The note can be authenticated and signed immediately.  If needed, the note can be forwarded from the clinic to the hospital or to a nursing facility or to a distant physician instantly.

The same electronic medical record system can be programmed to contain the patient's past medical history, a current accurate list of the patient's medications, and an active medical problem list for easy access by other physicians.  If there is a need to renew a prescription, it can be done and transmitted directly to the pharmacy through the patient's medical record in the computer.  This improves accuracy and keeps medical records current.

The question of confidentiality is critical.  At this time the patient's medical record is protected by no fewer than 4 separate pass words that I must use before I can access the patient's medical record.  Each of these passwords is committed to my memory are not available to anyone else.  Thus, as electronic medical records systems have been developed, the topic of patient confidentiality and protection has been paramount.  At this point it really appears to be very well protected.

I am still learning to use the Dragon-9 program.  It’s rather like learning to play the piano.  Just because I cannot yet play the Warsaw Concerto doesn't mean I can't learn and do it well later.  I'm coming along.  Happy Thanksgiving to all and my sincere hope for your good health.