Data kinds and the medical record

In my previous post, I described the two kinds of data that I think I see in most, if not all, applications. The two kinds are the “state reflecting record” (SRR) and the “transformation additive series” (TAS). Cumbersome names, I admit, but if you have a better idea, let’s hear it.

A medical record, be it on paper or in a computer, is built up of only a TAS, with no SRR in sight. That is, it consists of notes, each by a certain person and on a certain date and time, and added in chronological order. Each note consists of the patient’s complaints, results of examinations, answers from referrals, medication changes, conclusions, plans, or any combination of these. Even if the note contains a summary of earlier notes or a summary of the patient’s current state or history, this summary is still part of the note and thus embedded in a record that is just one element in a TAS.

In some systems you’ll find a summary document about the patient as a whole, and this document is updated with the most important new findings or treatments as you go along, but it has no direct connection to the chronological notes and is usually of such poor quality that it really can’t be considered an SRR.

The list of current medications, however, does qualify as an SRR, but its scope is limited to just medications. Interestingly, there is usually no TAS connected to this medication list, so the chronological information that is very important especially for medications, is missing or very hard to recover.

The most important information for the physician when seeing the patient is not when things happened or who made it happen or recorded whatever happened, but what the current state of the patient and his pathologies is. It used to be, back when patients had the same doctor for many years, that this information was stored inside the doctor’s head. The information he had trouble remembering, such as exactly when he did exactly what, was the only information that was recorded in the medical record.

But today, there generally isn’t any doctor around that knows the patient and the lack of a document describing the patient’s current state is a real problem. Doctors have developed a habit to reconstruct the current state of the patient from the historical records, but this is a very laborious and error prone process. What makes it worse is that it has to be reconstructed at every new encounter, since there is no way to store that current state so it can be reused and expanded upon at the next encounter. There simply is no such mechanism available in the medical records systems.

As a concrete example, let’s assume I see a patient for a general checkup. First, I have to scan through the notes to make a mental list of all the ailments he has or has had, while at the same time figuring out how each of those ailments have evolved and are currently treated. For instance, I may find a mention of a high blood glucose level three years ago, another high level a couple of months later, together with a conclusion that the patient has type 2 diabetes and that medication is started. Half a year later I find a note that the medication was insufficient and that a second product was added. The next three notes are about a stomachache the patient developed, and then I find another note telling me his diabetes is now under control. I haven’t seen any mention of an ophthalmology referral to check the state of the patient’s retinas, so I have to run through the notes one more time looking for that. If I don’t find any, I’ll have to write a referral note for that.

If I had had a form for diabetes type 2 with the medication field containing the current medications and the ophthalmology referral field still empty, I’d known all this in a flash and with a much greater confidence, but there is no such thing, so I’m forced to go through this frankly ridiculous process of reconstructing that form in my mind every time I see a patient.

Oh, and don’t forget, the patient may have several problems, each of which has to be evaluated like this. Some of these problems I don’t even know about until I run across them in some old note. Finally, once I’ve worked myself through this process, only then can I actually start working with the patient.

If we go back to the SRR vs TAS view of data, it’s clear that the SRR is simply missing and I have to reconstruct the SRR every time I see a new patient. This worked back in the time when I still remembered the state of the patient (the SRR) from the last time I saw the patient, but nowadays most patients I see I’ve never seen before, so this system fails abysmally.

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