If you’re not in the medical records field, that term is, shall we say, not very meaningful. But it has the force of billions of federal dollars behind it. It’s a catchphrase central to the monumental national effort now under way to get medical records off of paper and into electronic forms that can be — yes, indeed — used meaningfully to document and improve health care.
The federal government is overseeing an elaborate, multi-stage process to work out the guidelines for the software designers who create these electronic medical records. As they do, Ken Farbstein, a professional patient advocate, has a low-tech suggestion to offer: Make sure the electronic records can and will be translated into printed instructions for patients.
By Ken Farbstein
My dog Jackson was born to a stray mother, and he never knew Daddy. Jackson has never had health insurance. Now entering old age (at ten), he definitely has some risk factors for poor health: uninsured, born homeless into a single parent family, aging. Yet he gets excellent health care, and of special note, he routinely gets much clearer doctors’ orders than I do.
At the end of each well-dog checkup, and at every other visit to the veterinarian, he receives a printed four-page summary that describes notes from the exam and, highlighted in red ink, the steps we should take to keep him healthy.
We weren’t brushing his teeth, so the visit summary included a paragraph on the plaque and tartar that develops with poor dental hygiene. It even recommended the specific flavor of toothpaste he’d likely prefer: poultry. (A human patient might go “Balk!” at that.) Years ago, when we found a lump in his left front shoulder, the visit summary described what a lipoma was, with our treatment options. In a later visit we heard a shocking diagnosis of a cancerous tumor. In later rereading the visit summary, we absorbed more of it than when we had first gotten the diagnosis.
The vet’s electronic health record software makes it easy for the vet and the technician to produce these summaries, so promptly that the payment clerk can routinely hand the printout to us at the end of the visit. The information in the visit summary is significant, actionable, pertinent, timely and specific; in short, it’s highly meaningful. Continue reading