The Clinical Record: A 200-Year-Old 21st-Century Challenge

Editorials16 November 2010The Clinical Record: A 200-Year-Old 21st-Century ChallengeMichael S. Barr, MD, MBAMichael S. Barr, MD, MBAFrom American College of Physicians, Philadelphia, PA 19106.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-153-10-201011160-00015 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Apart from the case record, no mechanism exists in medicine that brings its diverse elements together. Improving these clinical portraits and striving to enlarge their usefulness must be central goals of medicine, for the case records are the works that define its essence.—Stanley J. Reiser, 1991 (1)This issue includes 2 articles that may initially seem unrelated. Siegler (2) gives us an extraordinary look at the evolution of medical records at The New York Hospital in the 1800s. Maxson and colleagues (3), from the Office of the National Coordinator for Health Information Technology, describe federal efforts to support the broad ...References1. Reiser SJ. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med. 1991;114:980-5. [PMID: 2024867] LinkGoogle Scholar2. Siegler EL. The evolving medical record. Ann Intern Med. 2010;153:671-7. LinkGoogle Scholar3. Maxson E, Jain S, Kendall M, Mostashari F, Blumenthal D. The Regional Extension Center program: helping physicians meaningfully use health information technology. Ann Intern Med. 2010;153:666-70. LinkGoogle Scholar4. American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, 123 Stat. 226 (2009). Google Scholar5. Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA. 2006;295:2335-6. [PMID: 16720812] CrossrefMedlineGoogle Scholar6. Snyder L, Leffler C; Ethics and Human Rights Committee. American College of Physicians. Ethics manual: fifth edition. Ann Intern Med. 2005;142:560-82. [PMID: 15809467] LinkGoogle Scholar7. Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. N Engl J Med. 2008;358:1656-8. [PMID: 18420497] CrossrefMedlineGoogle Scholar8. Reiser SJ. The clinical record in medicine. Part 1: Learning from cases. Ann Intern Med. 1991;114:902-7. [PMID: 2014953] LinkGoogle Scholar9. Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362:1066-9. [PMID: 20335582] CrossrefMedlineGoogle Scholar10. Kuhn TM, Barr MS, Gardner LA, Baker DW; for the Medical Informatics Subcommittee of the American College of Physicians. EHR-based quality measurement & reporting: critical for meaningful use and health care improvement. Policy Paper. Philadelphia: American Coll Physicians; 2010. Accessed at www.acponline.org/advocacy/where_we_stand/health_information_technology/ehrs.pdf on 27 September 2010. Google Scholar Author, Article, and Disclosure InformationAffiliations: From American College of Physicians, Philadelphia, PA 19106.Disclaimer: The views expressed are those of the author and do not necessarily reflect the views or policies of the American College of Physicians.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2235.Corresponding Author: Michael S. Barr, MD, MBA, Senior Vice President, Division of Medical Practice, Professionalism & Quality, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected]org. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Regional Extension Center Program: Helping Physicians Meaningfully Use Health Information Technology Emily Maxson , Sachin Jain , Mat Kendall , Farzad Mostashari , and David Blumenthal The Evolving Medical Record Eugenia L. Siegler Metrics Cited byDevelopment of a digital clinical pathway for emergency medicine: Lessons from usability testing and implementation failureAnalysis of Digital Documentation Speed and Sequence Using Digital Paper and Pen Technology During the Refugee Crisis in Europe: Content AnalysisPromoting Responsible Electronic Documentation: Validity Evidence for a Checklist to Assess Progress Notes in the Electronic Health RecordInternal medicine progress note writing attitudes and practices in an electronic health recordClinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of PhysiciansThomson Kuhn, MA, Peter Basch, MD, Michael Barr, MD, MBA, and Thomas Yackel, MD, MPH, MS,, for the Medical Informatics Committee of the American College of Physicians*Analysis of Documentation Speed Using Web-Based Medical Speech Recognition Technology: Randomized Controlled TrialHidden in plain sight: bias towards sick patients when sampling patients with sufficient electronic health record data for researchMedical Students’ Observations, Practices, and Attitudes Regarding Electronic Health Record Documentation 16 November 2010Volume 153, Issue 10Page: 682-683KeywordsClinical decision support systemsElectronic medical recordsForecastingHealth economicsHealth information technologyMotivationPatientsResearch facilitiesResearch quality assessmentVision ePublished: 16 November 2010 Issue Published: 16 November 2010 Copyright & PermissionsCopyright © 2010 by American College of Physicians. 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