At 5am, Mr. A rolls onto the medicine floor: the fifth and final new patient to be admitted that night. The 70-year-old is well-known to our institution from his near-monthly hospitalizations and his primary care doctor, cardiologist, podiatrist, ophthalmologist, and both of his endocrinologists all work in-house. Unfortunately, for the intern admitting him (and for Mr. A), this translates into a few hours-worth of prior blood test results, MRI reports, visit notes, and discharge summaries to peruse. Where to begin? How to find the key details buried in this hoard of information?
Electronic health records (EHRs) have brought to health care both a much-needed modernity and an emerging challenge: how do doctors manage the rapidly growing quantities of health records that we are responsible for reviewing and that (theoretically) help us take better care of our patients, so that we can extract critical information while spending more time with patients and less in front of a computer?
There is little question that electronic records trump the tree-killing alternative (eg. that Mark Twain autobiography-sized pile of faxed paper, one line of doctor-scrawl per page, documenting a patient’s stay at an outside facility). But even electronic records can become unwieldy in the form now used in most hospitals, including Mass General: clinical data organized by the date a note was written or a blood test was drawn.
Sorting through such files as quickly and effectively as possible is a skill that we must pick up early in residency. But what if a computer program could make this easier and more foolproof by pulling out the information we needed when we needed it? The technical term for this is “clinical summarization.” It’s a still rare feature that is gaining traction. Continue reading…