Comprehensive, accurate medical records are important for a variety of reasons.
Today, longitudinal patient records that capture a patient’s medical information from a variety of physicians, labs, clinics, hospitals and treatment sites not only provides a holistic view of the patient’s health history, but also provides a wealth of information that can be used to improve care and outcomes.
Health information management is defined as the collection and analysis of healthcare data to provide information for health care decisions involving patient care, institutional management, health care policies, planning and research. The name of the function changed from medical records management to health information management as enhancements in technology expanded responsibilities from managing paper records to managing the full scope of the process of collecting and sharing electronically-captured information among disparate entities.
The history of health information management begins with the simplest form of recording a patient’s symptoms, complaints and treatment for the use of one provider, to a comprehensive aggregation, integration and harmonization of data to support collaboration among providers, researchers and administrators.
The First Medical Records
The earliest forms of medical records were narratives written by ancient Greeks to document successful cures, share observations about symptoms and outcomes, and teach others who provided medical advice through these case studies. While written reports describing patients’ complaints and diagnoses predate the records of Simon Forman and Richard Napier – astrologers who documented clients’ medical questions and treatment – their records from 1596 to 1634 form the earliest complete collection of medical records in existence.
As healthcare advanced, physicians realized that the best way to continue improving diagnosing and treating illnesses was to carefully document observations and actions while treating patients – and share this information as a way to teach other health professionals.
As early as 1600, physicians offered advice on how to present information in a medical record, but it wasn’t until 1928 that the American College of Surgeons (ACOS) took steps to standardize the growing number of medical records by establishing the American Association of Record Librarians (AARL) – known today as the American Health Information Management Association (AHIMA). “Record librarians” was the term used because early medical records were documented on paper.
Standardization of medical records and growth of complete record-keeping continued from the 1920s through the 1960s, but records were paper-based.
The development of computers presented the opportunity to maintain records electronically, but the expense of purchasing and maintaining a mainframe, and the expense associated with storage of data, meant that only the largest organizations could use technology to handle medical records.
The field of health informatics, as it is known today, emerged when computer technology became sophisticated enough to manage large amounts of data. One of the earliest efforts took place under the jurisdiction of the American Society for Testing and Materials (ASTM). These first standards addressed laboratory message exchange, properties for electronic health record systems, data content, and health information system security.
The 1960s also saw the introduction of Medicare and Medicaid, which required nurses to collect data to document care for reimbursement. While computers were increasingly used for accounting and billing functions, the use of computers to collect and manage medical records was not common.
In 1964, El Camino Hospital in Mountain View, CA worked with Lockheed Corporation to develop a hospital information system that included medical records, but generally computer manufacturers did not understand the healthcare industry’s needs.
Organizations that did opt for a computer system that handled medical records offered limited access to records –access only available at the site it was created. Records often only contained information about the hospital stay and tests or treatments provided within the walls of the hospital.
Even though implementation of technology was slow, the need to standardize was recognized by several organizations, with SNOP by the American College of Pathology developing what would eventually become Systematized Nomenclature of Medicine (SNOMED) to systematize the language of pathology. Also, the concept of a Uniform Minimum Health Data Set (UMHDS) was formulated in an effort to develop national health data standards and guidelines.
As computers became smaller, software designed to support clinical functions for pharmacy, clinical laboratory, patient registration and billing began to proliferate. The disadvantage of these health information systems was their department-specific functions – they were not accessible by other departments.
The first attempt at a total, integrated health records system was implemented in a gynecology unit at the University Medical Center in Burlington, Vermont in 1971. Based on the problem-oriented medical record, the system was patient oriented – all disciplines included in care made notes in the record to provide an overview of care to see the relationship between conditions, treatments, costs and outcomes.
Acceptance of the Problem Oriented Medical Information System was not widespread due to resistance to share information across disciplines. Although the idea for collaborative care was presented in the 1970s, the acceptance of collaboration and enhanced communication supported by a holistic health record system did not take place until the 1990s — with the advent of managed care.
The introduction of diagnosis related groups (DRGs) and data required for reimbursement increased the need for hospitals to pull detailed information from clinical systems as well as financial systems to ensure claims payment.
Because personal computers and widespread health-related software applications had grown in popularity, hospital information technology (IT) staff were tasked with the responsibility to integrate multiple, disparate systems. As network solutions were developed, IT departments were able to connect financial and clinical systems – for limited functions.
But as technology advanced, in most cases, hospital departments still could not access information outside their own silos – preventing data-sharing from disparate system.
The introduction of the master patient index (MPI), a database of patient information used across all the departments of a healthcare organization in the 1980s laid the groundwork for initiatives such as The Indiana Network for Patient Care (INPC), the foundation for today’s Indiana Health Information Exchange. In 2017, the health information exchange (HIE) leverages an internally developed MPI that includes 100 hospitals, representing 38 health systems; 12,000 practices with over 20,000 providers; 1,100 Veterans Administration sites and 12 million patients.
As competition in healthcare created consolidation of individual hospitals to form health systems, the need for integration grew. Technology advances gave hospitals access to computing systems that could share information across disparate systems to set the stage for data-sharing.
In recognition of the expanded scope of its members’ role in health informatics and data management, the organization that began in 1928 as AARL underwent its fourth name change – to AHIMA. Health information professionals’ responsibility now expanded beyond the data included in a single hospital medical record to health information comprising the entire continuum of care.
As hospitals continued to merge into larger health systems and to acquire individual physician practices, the increased need for interoperability that supported data-sharing grew.
The importance of integrated electronic health records (EHRs) to enable providers to make better decisions grew, and more hospitals and physicians implemented them to reduce the incidence of medical error by improving the accuracy and clarity of medical records. In his 2004 State of the Union Address, President George W. Bush called for computerized health records – the beginning of the electronic health record (EHR) revolution.
Adoption of fully-functional EHRs grew more significantly with the passage of the American Recovery and Reinvestment Act (ARRA) in 2009. One of the measures included in ARRA was the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act promoted the concept of meaningful use of EHRs and supported financial incentives to encourage the adoption of EHRs and the interoperability necessary to share data among providers.
Also, the introduction of cloud computing for a wide range of industry, including healthcare, supported expanded networks that went beyond specific sites and locations to tie all entities in a health system or HIE together without a significant investment in new technology.
The increased volume of data, ease of access to data and the need for health information professionals to guide the management of health data has led to an increasing reliance on health informatics, which is defined by the American Medical Informatics Association (AMIA) as a field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technology.
In the 2010s
Increased focus on value-based care as opposed to fee-based care and a drive to improve patient outcomes propel the growing accumulation of data to support clinical as well as operational decisions in health care.
Just as clinicians in the 1920s understood the importance of previous health records as learning tools that would improve outcomes, healthcare professionals leverage data to enhance care on a larger scale — using tools that analyze population health data.
New delivery models, such as accountable care organizations (ACOs), are implemented to contain costs, promote collaboration and improve patient health care. While ACOs, HIEs and growing health system networks have EHR and other systems to collect data, there is still a gap in aggregating and harmonizing the information from various systems to produce data that can be easily analyzed.
While there is no crystal ball to predict the future, it is safe to say that as health systems grow and expand to include other hospitals, physician practices and outpatient clinics, and as the volume of data grows with expansion, the need to integrate and harmonize data to make it available to all users is critical. Finding the right platform to support and enable access to structured and unstructured data across disparate systems is the first step to better preparing for a value-based future.
Interoperability, data-sharing and access to information will continue to be a critical requirement for process improvement, ACO enablement, information exchange and development of population-specific care that improve outcomes.
Health information management is a critical role in healthcare today. To see how effective management of patient data – clinical and financial – can help healthcare organizations improve patient care and safety as well as operational processes, see these articles: Clinical Data Management – Best Practices for the Pros and 4 Ways Health Informatics is Transforming Healthcare.
Are you ready for the future?