Medical Records: A Historical Narrative

Advancements in Electronic Medical Records for Clinical Trials: Enhancing Data Management and Research Efficiency

Recent advancements in electronic medical records (EMRs) have transformed clinical trials and healthcare systems by improving data accuracy, regulatory compliance, and integration with decision support tools. These innovations enhance trial efficiency, streamline patient recruitment, and enable large-scale data analysis while bridging clinical practice with research. Despite these benefits, challenges such as data standardization, privacy concerns, and usability issues persist. Overcoming these barriers through policy reforms, technological innovations, and robust methodologies is essential to maximizing the potential of EMRs. We examine current developments, challenges, and future directions for optimizing EMRs in clinical trials and healthcare delivery.

Data linkage multiplies research insights across diverse healthcare sectors

In all fields of study, as well as government and commerce, high-quality data enables informed decision-making. Linking data from disparate sources multiplies the opportunities for novel insights and evidence-based decision-making for an increasingly large range of administrative, clinical, research, and population health use cases. In recent years, novel methods, including privacy-preserving record linkage methods, have emerged. However, regardless of the method, successful data linkage is highly dependent on data quality and completeness and has to be balanced by the increased risk of re-identification of the subsequently linked data. Opportunities for the future include sharing tools for responsible linkage across silos, enhancing data to improve quality and completeness, and ensuring linkage leverages inclusive and representative datasets to ensure a balance between individual privacy and representation in research and novel discoveries. Here we provide a brief overview of the history and current state of data linkage, highlight the opportunities created by linked population data across critical research sectors, and describe the technology and policies that govern its usage.

Charting Diagnostic Safety: Exploring Patient-Provider Discordance in Medical Record Documentation

BACKGROUND

The 21st Century Cures Act enables patients to access their medical records, thus providing a unique opportunity to engage patients in their diagnostic journey.

OBJECTIVE

To explore the concordance between patients' self-reported diagnostic concerns and clinician-interpreted information in their electronic health records.

DESIGN

We conducted a mixed-methods analysis of a cohort of 467 patients who completed a structured data collection instrument (the Safer Dx Patient) to identify diagnostic concerns while reviewing their clinician's notes. We conducted a qualitative content analysis of open-ended responses on both the tools and the case summaries. Two clinical chart reviewers, blinded to patient-reported diagnostic concerns, independently conducted chart reviews using a different structured instrument (the Revised Safer Dx Instrument) to identify diagnostic concerns and generate case summaries. The primary outcome variable was chart review-identified diagnostic concerns. Multivariate logistic regression tested whether the primary outcome was concordant with patient-reported diagnostic concerns.

SETTING

Geisinger, a large integrated healthcare organization in rural and semi-urban Pennsylvania.

PARTICIPANTS

Cohort of adult patients actively using patient portals and identified as "at-risk" for diagnostic concerns using an electronic trigger algorithm based on unexpected visit patterns in a primary care setting.

RESULTS

In 467 cohort patients, chart review identified 31 (6.4%) diagnostic concerns, of which only 11 (21.5%) overlapped with 51 patient-reported diagnostic concerns. Content analysis revealed several areas of discordant understanding of the diagnostic process between clinicians and patients. Multivariate logistic regression analysis showed that clinician-identified diagnostic concerns were associated with patients who self-reported "I feel I was incorrectly diagnosed during my visit" (odds ratio 1.65, 95% CI 1.17-2.3, p < 0.05).

CONCLUSION

Patients and clinicians appear to have certain differences in their mental models of what is considered a diagnostic concern. Efforts to integrate patient perspectives and experiences with the diagnostic process can lead to better measurement of diagnostic safety.

Future Use of AI in Diagnostic Medicine: 2-Wave Cross-Sectional Survey Study

BACKGROUND

The rapid evolution of artificial intelligence (AI) presents transformative potential for diagnostic medicine, offering opportunities to enhance diagnostic accuracy, reduce costs, and improve patient outcomes.

OBJECTIVE

This study aimed to assess the expected future impact of AI on diagnostic medicine by comparing global researchers' expectations using 2 cross-sectional surveys.

METHODS

The surveys were conducted in September 2020 and February 2023. Each survey captured a 10-year projection horizon, gathering insights from >3700 researchers with expertise in AI and diagnostic medicine from all over the world. The survey sought to understand the perceived benefits, integration challenges, and evolving attitudes toward AI use in diagnostic settings.

RESULTS

Results indicated a strong expectation among researchers that AI will substantially influence diagnostic medicine within the next decade. Key anticipated benefits include enhanced diagnostic reliability, reduced screening costs, improved patient care, and decreased physician workload, addressing the growing demand for diagnostic services outpacing the supply of medical professionals. Specifically, x-ray diagnosis, heart rhythm interpretation, and skin malignancy detection were identified as the diagnostic tools most likely to be integrated with AI technologies due to their maturity and existing AI applications. The surveys highlighted the growing optimism regarding AI's ability to transform traditional diagnostic pathways and enhance clinical decision-making processes. Furthermore, the study identified barriers to the integration of AI in diagnostic medicine. The primary challenges cited were the difficulties of embedding AI within existing clinical workflows, ethical and regulatory concerns, and data privacy issues. Respondents emphasized uncertainties around legal responsibility and accountability for AI-supported clinical decisions, data protection challenges, and the need for robust regulatory frameworks to ensure safe AI deployment. Ethical concerns, particularly those related to algorithmic transparency and bias, were noted as increasingly critical, reflecting a heightened awareness of the potential risks associated with AI adoption in clinical settings. Differences between the 2 survey waves indicated a growing focus on ethical and regulatory issues, suggesting an evolving recognition of these challenges over time.

CONCLUSIONS

Despite these barriers, there was notable consistency in researchers' expectations across the 2 survey periods, indicating a stable and sustained outlook on AI's transformative potential in diagnostic medicine. The findings show the need for interdisciplinary collaboration among clinicians, AI developers, and regulators to address ethical and practical challenges while maximizing AI's benefits. This study offers insights into the projected trajectory of AI in diagnostic medicine, guiding stakeholders, including health care providers, policy makers, and technology developers, on navigating the opportunities and challenges of AI integration.

An exploratory study of electronic medical record implementation and recordkeeping culture: the case of hospitals in Indonesia

BACKGROUND

The digitization of healthcare, through electronic medical records (EMRs), is recognized globally as a transformative initiative. Indonesia mandated all healthcare facilities to adopt EMRs by December 31, 2023. However, this transition is complicated by diverse technological, cultural, and infrastructural challenges, with little research addressing the recordkeeping culture's impact on EMR adoption. This study investigates the electronic recordkeeping culture in Indonesian hospitals following a government mandate to adopt Electronic Medical Records (EMRs). It aims to understand the readiness and challenges in implementing EMRs across hospitals on Java and Sulawesi islands, focusing on infrastructure, staff digital skills, and varied adoption approaches.

METHODS

A qualitative case study approach was utilized, involving focus groups and semi-structured interviews with 150 staff from 12 hospitals. Conducted between November 2023 and June 2024, the study applied thematic analysis based on Oliver and Foscarini's (2020) recordkeeping culture framework to explore organizational readiness, technological infrastructure, and healthcare professionals' skills in managing electronic records.

RESULTS

The findings reveal significant differences in EMR adoption between the islands. Hospitals on Java exhibited proactive engagement, supported by better technological infrastructure and staff training programs, while Sulawesi hospitals adopted EMRs primarily to meet regulatory requirements. Challenges included inconsistent internet connectivity, low digital literacy among staff, and ongoing reliance on paper records during the transition. Some Java hospitals have begun fostering a culture conducive to electronic recordkeeping by focusing on developing staff skills in EMR management.

CONCLUSIONS

The effectiveness of EMR adoption in Indonesia relies on addressing technological infrastructure issues and enhancing staff digital literacy. While progress has been made, particularly in more developed regions, a cohesive national strategy emphasizing technological support and targeted training is essential to fully realize the benefits of EMRs in improving healthcare and recordkeeping standards across Indonesia.

Interdisciplinary systems may restore the healthcare professional-patient relationship in electronic health systems

OBJECTIVE

To develop a framework that models the impact of electronic health record (EHR) systems on healthcare professionals' well-being and their relationships with patients, using interdisciplinary insights to guide machine learning in identifying value patterns important to healthcare professionals in EHR systems.

MATERIALS AND METHODS

A theoretical framework of EHR systems' implementation was developed using interdisciplinary literature from healthcare, information systems, and management science focusing on the systems approach, clinical decision-making, and interface terminologies.

OBSERVATIONS

Healthcare professionals balance personal norms of narrative and data-driven communication in knowledge creation for EHRs by integrating detailed patient stories with structured data. This integration forms 2 learning loops that create tension in the healthcare professional-patient relationship, shaping how healthcare professionals apply their values in care delivery. The manifestation of this value tension in EHRs directly affects the well-being of healthcare professionals.

DISCUSSION

Understanding the value tension learning loop between structured data and narrative forms lays the groundwork for future studies of how healthcare professionals use EHRs to deliver care, emphasizing their well-being and patient relationships through a sociotechnical lens.

CONCLUSION

EHR systems can improve the healthcare professional-patient relationship and healthcare professional well-being by integrating norms and values into pattern recognition of narrative and data communication forms.

Twenty-Five Years of Evolution and Hurdles in Electronic Health Records and Interoperability in Medical Research: Comprehensive Review

BACKGROUND

Electronic health records (EHRs) facilitate the accessibility and sharing of patient data among various health care providers, contributing to more coordinated and efficient care.

OBJECTIVE

This study aimed to summarize the evolution of secondary use of EHRs and their interoperability in medical research over the past 25 years.

METHODS

We conducted an extensive literature search in the PubMed, Scopus, and Web of Science databases using the keywords Electronic health record and Electronic medical record in the title or abstract and Medical research in all fields from 2000 to 2024. Specific terms were applied to different time periods.

RESULTS

The review yielded 2212 studies, all of which were then screened and processed in a structured manner. Of these 2212 studies, 2102 (93.03%) were included in the review analysis, of which 1079 (51.33%) studies were from 2000 to 2009, 582 (27.69%) were from 2010 to 2019, 251 (11.94%) were from 2020 to 2023, and 190 (9.04%) were from 2024.

CONCLUSIONS

The evolution of EHRs marks an important milestone in health care's journey toward integrating technology and medicine. From early documentation practices to the sophisticated use of artificial intelligence and big data analytics today, EHRs have become central to improving patient care, enhancing public health surveillance, and advancing medical research.

Using journalling to support nurses' mental well-being and self-care in challenging times

Nurses frequently experience multiple challenges and face numerous demands in their professional role, which may lead to adverse effects such as stress, depression, anxiety and burnout. Therefore, it is important to identify effective and accessible strategies that can support them. This article explores how nurses can use journalling as a tool for navigating the challenges they experience in their practice. It offers a step-by-step guide that provides nurses with an accessible and effective approach to journalling, which they can use to support their mental well-being and self-care.

The Impact of Diagnosis-Specific Plan Templates on Admission Note Writing Time: A Quality Improvement Initiative

Background There are limited objective studies regarding the effectiveness of strategies to alleviate the documentation burden on resident physicians. Objective To develop and implement diagnosis-specific templates for the plan of care section of inpatient admission notes, aiming to reduce documentation time. Methods Twelve templates for the plan of care section of admission notes were written by the study authors, reviewed by attending physicians, and shared with the residents through the electronic health record (EHR) on September 23, 2022. EHR audit log data were collected to examine admission note writing times, supplemented by resident feedback on acceptability via an anonymous survey. Feasibility measures included time investment, experience with the EHR, and resident training. Results Between July 1, 2021 and June 30, 2023, 62 pediatric residents contributed 9840 admission notes. The templates were used in 557 admission notes. The mean total time spent on an admission note decreased from 97.9 minutes pre-intervention to 71.0 minutes post-intervention with the use of a template; an adjusted reduction of 23% (95% CI 16%-30%; P<.001). The mean attending time spent editing an admission note was unchanged. The survey results underscored wide acceptability of the templates among the residents. Feasibility data showed that the project required minimal time investment from the health care informatics team and minimal resident training. Conclusions Using templates in the care plan section of admission notes reduces the time residents spend writing admission notes.

A scoping review of the drivers and barriers influencing healthcare professionals' behavioral intentions to comply with electronic health record data privacy policy

Objective: Electronic Health Records (EHRs) are now an integral part of health systems in middle and high-income countries despite recognized deficits in the digital competencies of Healthcare Professionals (HCPs). Therefore, we undertook a scoping review of factors influencing compliance with EHR data privacy policies. Methods: Seven databases revealed 27 relevant studies, covering a range of countries, professional groups, and research methods. The diverse nature of these factors meant that 18 separate theoretical frameworks representing technology-acceptance to behavioral psychology were used to interpret these. Results: The predominant factors influencing compliance with EHR data privacy policies included confidence and competence to comply, perceived ease of use, facilitatory environmental factors, perceived usefulness, fear that non-compliance would be detected and/or punished and the expectations of others. Conclusion: Human factors such as attitudes, social pressure, confidence, and perceived usefulness are as important as technical factors and must be addressed to improve compliance.

For Whom the Note Scrolls: A Brief History of the Medical Record's Role in Education and the Risks It Faces in the Age of OpenNotes

Dating back to ancient civilizations when records were carefully transcribed onto papyrus, clinical documentation has long served as a cornerstone of medical-and especially neurologic-education. From the case histories of Hippocrates to the diurnal patient logs used by trainees in the 18th and 19th centuries, clinical notes have an extended history as invaluable instruments of pedagogy, scholarly practice, and interprofessional communication. The novel paradigm introduced by Lawrence Weed in the 1950s, advocating for the problem-oriented medical record system, revolutionized the clinical note template and emphasized the need for physicians' carefully considered analyses of a patient's presentation to be clearly reflected in well-organized documentation. In the realm of medical records today, however, a profound shift is underway, largely propelled by the emergence of electronic medical records, the OpenNotes mandate of the federal 21st Century Cures Act, and, most recently, artificial intelligence (AI). Appropriately, patients now have full access to their medical records, but this raises critical questions. Should clinical notes now prioritize patient comprehension over their traditional role as educational instruments, aide-mémoire, and repositories of detailed assessments and insights? What role, if any, should AI have in the creation of physician notes and patient-facing clinical documents? These tensions underscore the delicate balance between transparency and the preservation of notes' clinical integrity and analytical depth. As we navigate the path forward, finding an equilibrium between openness and the continued utility of medical records as tools for education and professional communication will be imperative.

Fifteenth century Florentine mural investigated in situ with VNIR Hyperspectral Imaging and NIR Photography supports interpretation as a bloodletting scene

This study provides new data which suggest a novel interpretative hypothesis not only on the specific painting, but on the use of bloodletting as medical practice in the Florentine Quattrocento. As a part of a cycle of frescoes devoted to the Seven Corporal Works of Mercy, the examined lunette depicts the "Visit to the sick" in a domestic interior, but it has never been considered as an historical document of precise medical practices. The scene's definitive interpretation is still unresolved because of the uncertainty of some iconographic details. A campaign of in-situ and non-invasive technical investigations was performed to retrieve possible traces of previous details today concealed. The technical solutions adopted to implement the measurements campaign are illustrated, as an experimental example for remote sensing inspection of mural paintings in-situ. The position of the painting high up on a wall of an historical venue led to opting for stand-alone optical imaging techniques which could operate in remote sensing mode. By combining the use of portable Hyperspectral Imaging with Near Infrared photography a set of detailed images could be obtained that highlighted details not otherwise detectable. Focused on the objects held by the persons present, the analysis of the mural of Visit of the Buonomini in her Lying in Bed, the gift of swaddling cloth could be a tourniquet, shadows of folds of a blanket a thumb lancet, and an object held a blood collection bowl, supported the hypothesis that it could be a medieval bloodletting scene.

A context-driven approach through stakeholder engagement to introduce a digital emergency obstetric and newborn care register into routine obstetric health care services in Bangladesh

Background

Emergency obstetric and newborn care (EmONC) in Bangladesh focusses on maternal health, whereby it addresses childbirth and postpartum complications to ensure women's health and well-being. It was transitioned to a digital platform to overcome challenges with the paper-based EmONC register and we conducted implementation research to assess the outcome. Here we outline the stakeholder engagement process integral to the implementation research process.

Methods

We adopted a four-step stakeholder engagement model based on the identification, sensitisation, involvement, and engagement of stakeholders. The approach was informed by previous experience, desk reviews, and expert consultations to ensure comprehensive engagement with stakeholders at multiple levels. Led by the Maternal Health Programme of the Government of Bangladesh, we involved high-power and high-interest stakeholders in developing a joint action plan for digitisation of the paper-based EmONC register. Finally, we demonstrated this digital EmONC register in real-life settings to stakeholders at different levels.

Results

The successful demonstration process fostered government ownership and collaboration with multiple stakeholders, while laying the foundation for scalability and sustainability. Nevertheless, our experience highlighted that the stakeholder engagement process is context-driven, time-consuming, resource-intensive, iterative, and dynamic, and it requires involving stakeholders with varied expertise. Effective strategic planning, facilitation, and the allocation of sufficient time and resources are essential components for successful stakeholder engagement.

Conclusions

Our experience demonstrates the potential of adopting the 'identification, sensitisation, involvement, and engagement' stakeholder engagement model. Success in implementing this model in diverse settings depends on leveraging knowledge gained during implementation, maintaining robust communication with stakeholders, and harnessing the patience and determination of the facilitating organisation.

Implementation of a Real-Time Documentation Assistance Tool: Automated Diagnosis (AutoDx)

BACKGROUND

 Clinical documentation improvement programs are utilized by most health care systems to enhance provider documentation. Suggestions are sent to providers in a variety of ways, and are commonly referred to as coding queries. Responding to these coding queries can require significant provider time and do not often align with workflows. To enhance provider documentation in a more consistent manner without creating undue burden, alternative strategies are required.

OBJECTIVES

 The aim of this study is to evaluate the impact of a real-time documentation assistance tool, named AutoDx, on the volume of coding queries and encounter-level outcome metrics, including case-mix index (CMI).

METHODS

 The AutoDx tool was developed utilizing tools existing within the electronic health record, and is based on the generation of messages when clinical conditions are met. These messages appear within provider notes and required little to no interaction. Initial diagnoses included in the tool were electrolyte deficiencies, obesity, and malnutrition. The tool was piloted in a cohort of Hospital Medicine providers, then expanded to the Neuro Intensive Care Unit (NICU), with addition diagnoses being added.

RESULTS

 The initial Hospital Medicine implementation evaluation included 590 encounters pre- and 531 post-implementation. The volume of coding queries decreased 57% (p < 0.0001) for the targeted diagnoses compared with 6% (p = 0.77) in other high-volume diagnoses. In the NICU cohort, 829 encounters pre-implementation were compared with 680 post. The proportion of AutoDx coding queries compared with all other coding queries decreased from 54.9 to 37.1% (p < 0.0001). During the same period, CMI demonstrated a significant increase post-implementation (4.00 vs. 4.55, p = 0.02).

CONCLUSION

 The real-time documentation assistance tool led to a significant decrease in coding queries for targeted diagnoses in two unique provider cohorts. This improvement was also associated with a significant increase in CMI during the implementation time period.

'This wretched state': Robert Burns's illness and the daybook of Charles Fleeming

While now known globally as Scotland's national poet, in November 1781 the daybook of surgeon Charles Fleeming simply records him as 'Robert Burns, Lint Dresser'. Discovered in the 1950s, the daybook documents Fleeming's treatment of Burns during a period of illness which would have a profound impact on the poet's life and creative output. The book's discovery added to the theories about the nature of Burns's illness, often at odds with Burns's own later descriptions. This paper presents a fresh examination of Burns's treatment, challenging those theories by considering Fleeming's prescriptions in the context of key medical authorities of the time. In considering Burns's entry in the daybook in its entirety, the wider value of Fleeming's daybook as a private record of medical practice at the time is highlighted, pointing to the potential value of this and other such volumes as underappreciated archival research material.

Moving Toward More Person-Centered Language in Maternity Care

Using person-centered language can help clinicians find alternatives that are more patient-centered, empathetic, and inclusive to support the delivery of high-quality health care.

Evolution of Hybrid Intelligence and Its Application in Evidence-Based Medicine: A Review

Modern medicine, both in clinical practice and research, has become more and more based on data, which is changing equally in type and quality with the advent and development of healthcare digitalization. The first part of the present paper aims to present the steps through which data, and subsequently clinical and research practice, have evolved from paper-based to digital, proposing a possible future of this digitalization in terms of potential applications and integration of digital tools in medical practice. Noting that digitalization is no more a possible future, but a concrete reality, there is a strong need for a new definition of evidence-based medicine, which must take into account the progressive integration of artificial intelligence (AI) in all decision-making processes. So, leaving behind the traditional research concept of human intelligence versus AI, poorly adaptable to real-world clinical practice, a Human and AI hybrid model, seen as a deep integration of AI and human thinking, is proposed as a new healthcare governance system. The second part of our review is focused on some of the major challenges the digitalization process has to face, particularly privacy issues, system complexity and opacity, and ethical concerns related to legal aspects and healthcare disparities. Analyzing these open issues, we aim to present some of the future directions that in our opinion should be pursued to implement AI in clinical practice.

Expanding Quality by Design Principles to Support 3D Printed Medical Device Development Following the Renewed Regulatory Framework in Europe

The vast scope of 3D printing has ignited the production of tailored medical device (MD) development and catalyzed a paradigm shift in the health-care industry, particularly following the COVID pandemic. This review aims to provide an update on the current progress and emerging opportunities for additive manufacturing following the introduction of the new medical device regulation (MDR) within the EU. The advent of early-phase implementation of the Quality by Design (QbD) quality management framework in MD development is a focal point. The application of a regulatory supported QbD concept will ensure successful MD development, as well as pointing out the current challenges of 3D bioprinting. Utilizing a QbD scientific and risk-management approach ensures the acceleration of MD development in a more targeted way by building in all stakeholders' expectations, namely those of the patients, the biomedical industry, and regulatory bodies.