Hubris

One File per Patient

Index

Paper notes could be moved

One of the most obvious features of the old Lloyd George envelopes was that they could move with the patient from practice to practice. Indeed there are still a substantial number of envelopes which contain a full record spanning the period from before the NHS took over until now.

Current electronic records cannot be moved from practice to practice, even at present as unformatted text, although the TextBase project may loosen that up a little.

Paper notes could be removed

In addition, once a paper note moved to another practice it had by definition been removed from the first, and it was rare for practices to retain a copy. Occasionally it will seem appropriate to remove the records of a particular patient from a practices' database. Holland gives its citizens the explicit right to have this done, and our Data Protection Act may indicate this is necessary sometimes.

The trouble and expense of removing one patient's entries from a relational database EMR appear considerable, and the effects on the validity of the audit trail interesting.

The Medical Record as a single file for each patient

If we go away a little from the view of the EMR as a sort of faster card file, and toward the view of it being a story about a patient, it becomes apparent that a document not a million miles from a Word for Windows document could hold the narrative of the story.

Certain parts of the medical record are both formatted and organised, blood pressure measurements for instance, and immunisation records, and these would be best dealt with as structured elements embedded in the file. Consider as an example an Excel worksheet with the immunisations, with a bookmark to locate it from the table of contents.

The internal structure and size of Word files may not make them the first candidate for such systems, but they are excellent for thought experiments.

But the audit trail...

Word of course supports redlining - altered text shows it has been altered, and in later versions shows who altered it and when, the multiple versions can be restored, sequentially, reconstructing th edocument at any previous time.

There is an audit trail in there somewhere, the question is can it be made as tamper proof as the existing audit trails.

Database technology is essential for searches...?

Search the Web - for anything.

The huge number of structured text files on the web are indexed separately by search engines which actually have many interesting features for medical records purposes. The Excite "documents more like this" feature is a particularly interesting one. Imagine pulling up the record of a man who has just had an early death, and asking the search engine for "documents more like this", and being presented with the notes of the patients who the search engine finds to have notable similarities to the departed one.

Far fetched? Artificial Intelligence fantasy rather than good solid computer engineering? Certainly at present not wholly reliable, but neither are the coding schemes we partially impose upon some of ourselves some of the time in order that our databases may return all patients with CVS disease, or Diabetes, or impotence (not a commonly coded symptom, and just about to become a useful one to keep count of with Viagra arriving.

Weblike search engines searching for precise Read Code phrases picked from a dictionary and placed in a text/XML/Word file among other text would work as well as searches on the Read Code index in our current databases. And in addition, if the relevant wors had been typed in freehand they would be picked up.

It is entirely possible that the combination of free text entry (with optional code selection) and fuzzy searching would be more congenial to GPs, and therefore used more effectively with an end result of an increased accuracy of disease registers and the demand forecasting that we desire in order to run the health service more effectively.

Interoperability and interfaces

If we find ourselves using a browser front end, running over a TCP/IP network, perhaps even an NHS wide intranet, displaying information from a variety of practice systems, then even if it only shows a picture of the old text-based screen we will have defined a de facto standard for notes format, the HTML packages being sent over the net.

From there to using that format to store the notes in is a relatively small step.

And it is a step which we should continue to consider

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