Streamlining medical records
With the help of an electronic medical record, breast cancer specialist Lawrence Shulman, MD, discusses Rebecca Dinning's health history.
Health information for Dana-Farber adult patients began its slow journey away from paper in 2003, with the phasing in of the longitudinal medical record (LMR). Now used by most adult clinical areas at Dana-Farber, this outpatient software program includes clinic and nursing notes; flow sheets that show vital signs, laboratory test results, pathology and radiology reports, and office visits; documentation of any chemotherapy given; and an updated list of medications, allergies, and blood counts.
The LMR also includes many patient safety features. For example, it alerts a clinician if the patient is allergic to a medication being ordered, or if the drug will not mix with another the patient is taking. Today, a typical DFCI medical record is both electronic and paper. Garber's chart, for example, is stored among thousands of others at Dana-Farber, and he carries it from clinic to clinic when he comes for appointments.
But an online medical record is more current and cannot be misplaced the way a paper one can. Clinicians can write prescriptions online, then print out a slip for a patient; there is no hasty handwriting for a pharmacist to decipher. As with the computerized drugordering system, standardization is another LMR advantage. With point-and-click features and annotated diagrams, each record includes similar information.
Shulman, who specializes in treating breast cancer, reports that most of his patients understand and appreciate the LMR. "Today, technology gives me the chance to know the results of my patient's mammogram, because I see it on my screen, just before she walks in. In the old days, she had to tell me about it. She might say, 'I had a mammogram last week,' and I would leave her waiting while I went back into my office to track down the radiologist and get the results."
Adult DFCI patients who also receive inpatient care at Brigham and Women's have two electronic records, since the LMR is only an outpatient program. However, the still-evolving system can be viewed from other locations, such as the BWH emergency room.
Looking ahead, an initiative known as Patient Gateway is now being tested and will enable adult patients to schedule appointments and communicate with their clinicians by e-mail. Another feature under consideration is "journaling," which would allow patients to note in their record how they are feeling between their visits.
