ABSTRACT
Through a combination of governmental and private incentives, a transformation of medical records into an electronic medical record (EMR) format is spreading rapidly. Proponents of transformation to the EMR promised a number of improvements in healthcare, but disturbing signs of possible adverse effects have surfaced. In particular, we are concerned about the inability of the current records to adequately communicate the complex, information-in-context contained in many medical records as well as the emergence of diagnosis that results from time-dependent analysis and review of a problem. We investigated the complexity of structure in three EMR as an initial step, and contrasted these findings with those
in transcribed paper records, dictated reports, and articles in biomedical journals. We found a marked difference in function words, suggesting a limitation on the transfer of information-in-context in the EMR. When the wide choice of narrative and its extensive vocabulary is exchanged for limited choices in a list, the length of the message must be extended to transmit the same amount of information. This limitation on contextual information in turn has subtle, yet profoundly significant, implications for the behavior of physicians and other healthcare professionals. 10.1 IntroductionThe application of EMR to healthcare has long been the goal of governments in the United States and abroad. The 2009 American Recovery and Reinvestment Act set the goal of utilization of an EMR for every citizen by 2014.1 The Congressional Budget Office estimated the health IT provisions of this bill would amount to 18 billion USD added to the deficit over 11 years.2 Proponents of the EMR point to benefits that will result from this adoption3,4: • complete and accurate information • better access to information • patient empowerment • better decision making • overall cost savingsGreenhalgh and co-authors question, however, whether these benefits will actually accrue. Moreover, they are concerned about the potential unconscious biases, tensions, and paradox in published studies on the subject.5 Of particular interest is the tension between “knowledge as transferable fact” and “knowledge as information-in-context.” A positivist approach to EMR assumes the former, and that the decision support offered by EMR will eventually improve quality, even though the evidence has not shown it yet. The alternative view is that major advances in quality are unlikely to occur as healthcare is filled with contextual information rife with exceptions to general rules. The view that healthcare is filled with exceptions and contextual information is bolstered by the numerous articles that describe healthcare delivery as a complex
adaptive system (CAS).6-8 Such research begs the question: Do the records of healthcare share this understanding of the primary activity of healthcare delivery being a CAS? We think not.Complex, contextual information is most easily transmitted through narrative.9 It is well recognized by authors such as Greenhalgh and Hurwitz that the study of narrative in medicine offers an added dimension of understanding the context of disease.10,11 Thus, the most accurate and fullest transfer of contextual information should be an important aspect of any EMR. Unfortunately, this is precisely the area that is lost in many iterations of EMR.12 Template-driven drop-down lists take the place of dictated descriptions. We question if the limitations in the structural complexity of EMR is a restrictive factor in the communication of the complexity of content.The medical record is a means for asynchronously transmitting the context-rich information contributed by the patient in the history, as well as the equally context-rich information produced as a result of the physical examination on the part of the various providers. Additional contextual information elicited by ancillary studies is subsequently added. Each step of the process is highly influenced by the starting point and non-linear relationships with multiple factors. At each step, the availability of information as well as its quality will influence the subsequent course of the process. Treatment “emerges” from an evaluation process steeped in oral narrative.What is altered by the change from an oral narrative to a written account? Most physicians would think very little. However, the effect of the medium on the message has been the focus of study by the members of what has become to be known as the Toronto School of Communication.13 Perhaps the best known of this school of thought, Marshall McLuhan, coined the famous phrase “the medium is the message” to illustrate the influence the communication technology had on the content of the communication, as well as the thought processes of the originator.14
