The History of our Medical Records
Updated: Nov 12, 2019
What does the term medical record mean to you? Quite simply, a medical record is the total documentation of a patients' medical information from birth - a complex range of 'notes' that includes documentation from previous consultations, previous administration of specific drugs, test results including x-rays and any surgical operations to name a few.
The origin of the medical record can be traced back to the ancient Greek times where they would document observations they had, successful cures and shared their opinions as a means to educate others. The medical record has seen significant changes since then but what do we see the future of the medical record to look like?
A look back in time at the history of the patient Medical Record
Europe saw its first formal medical record system, developed in Sweden. Systematic medical documentation was introduced in connection with the opening of Seraphim Hospital in Stockholm (1792).
The turn of the 20th century brought with it a better understanding of the benefits of recording patients medical data. Healthcare providers realised that they were better able to treat patients if they had complete and accurate records of their medical history. This encouraged practitioners in 1920s to pressurise their healthcare organisations to keep patient records - what we know as Health Information Management. As a result, the information healthcare organisations were gathering about their patients grew and grew and encouraged the adoption of the Tabulating Machine. Developed by Herman Hollerith in the 1880s, it was used to manage medical information as it became too difficult for hospitals to keep all written patient records.
GPs in England have been keeping a lifelong record of registered patients - either on paper or a digital record - since 1928.
The 1960s saw the development of the electronic computer. At that time a technological milestone, it created the opportunity to manage patient's medical records electronically. The original health management systems originated in the mid-1960s and focused specifically on clinical data management.
Larry Weed, MD, introduced the Problem-Oriented Medical Record (POMR), which focused on a patient problem list and consisted of history, physical examination, laboratory data, complete problem list, initial plans, daily progress notes, and discharge summary. This is now seen as one of the most successful attempts to improve the collection of patient records.
The number of healthcare organisations using computers to sort patient records rose steadily. This was because the use of these computers became more cost-effective in sorting their patient's health information - as a result, issues arose around the protection of this information, including privacy concerns.
In 1972 the first official Electronic Medical Health Record (EHR) was developed by the Regenstrief Institute (USA). This innovation was slow to take off, however, due to the high costs involved in the development and lack of evidence to support its implementation.
In the UK, the Access to Medical Reports Act 1988 was introduced. It gives patients the right to see reports written about them by a doctor for employment or insurance purposes with whom they have a normal doctor-patient relationship.
In the UK the Access to Health Records Act 1990 was introduced, an act of the Parliament of the United Kingdom which applies to people in England, Wales and Scotland. It allows patients, and in some cases their representatives, to inspect their own records, and if necessary to an explanation of terms which are not intelligible without explanation.
In England, patients have had the legal right to access their health records since 1998.
The importance of integrated electronic health records to be developed became grew stronger as evidence showed they allowed healthcare providers to make better decisions for their patients.
President George W. Bush called for computerised health records – the beginning of the electronic health record (EHR) revolution (2004).
Jeremy Hunt announced in September 2015 that all patients will be entitled to read and write to all their NHS health records online by 2018(2015).
In the US, 96 per cent of hospitals and 87 per cent of office-based physician practices were using Electronic Health Records (EHRs)(2015).
In England, the percentage of general practice surgeries that allowed patients to access their medical records online increased from 3% to 97% between April 2014 and February 2016.
What Lies Ahead?
Access to information and interoperability will continue to be the topic of conversation for the future of medical records. This accelerating trend towards patient access and patient-centric process models now highlights the need for patients health reports to be more readily available and the information included to be easily understood. It is the job of healthcare organisations to identify the right solution that will enable patient access to their medical reports, achieving the overall aim of better engaging and empowering patients to make informed healthcare decisions and to improve the on-going relationship between the patient and their healthcare organisation.