. The name of the function changed from medical records management to health information management as enhancements in technology expanded responsibilities from managing paper records to managing the full scope of the process of collecting and sharing electronically-captured information among disparate entities.
The history of health information management begins with the simplest form of recording a patient’s symptoms, complaints and treatment for the use of one provider, to a comprehensive aggregation, integration and harmonization of data to support collaboration among providers, researchers and administrators.
The First Medical Records
The earliest forms of medical records were narratives written by ancient Greeks to document successful cures, share observations about symptoms and outcomes, and teach others who provided medical advice through these case studies. While written reports describing patients’ complaints and diagnoses predate the records of Simon Forman and Richard Napier – astrologers who documented clients’ medical questions and treatment – their records from 1596 to 1634 form the earliest complete collection of medical records in existence.
As healthcare advanced, physicians realized that the best way to continue improving diagnosing and treating illnesses was to carefully document observations and actions while treating patients – and share this information as a way to teach other health professionals.
As early as 1600, physicians offered advice on how to present information in a medical record, but it wasn’t until 1928 that the American College of Surgeons (ACOS) took steps to standardize the growing number of medical records by establishing the American Association of Record Librarians (AARL) – known today as the American Health Information Management Association (AHIMA). “Record librarians” was the term used because early medical records were documented on paper.
Standardization of medical records and growth of complete record-keeping continued from the 1920s through the 1960s, but records were paper-based.
The development of computers presented the opportunity to maintain records electronically, but the expense of purchasing and maintaining a mainframe, and the expense associated with storage of data, meant that only the largest organizations could use technology to handle medical records.
The field of health informatics, as it is known today, emerged when computer technology became sophisticated enough to manage large amounts of data. One of the earliest efforts took place under the jurisdiction of the American Society for Testing and Materials (ASTM). These first standards addressed laboratory message exchange, properties for electronic health record systems, data content, and health information system security.
As computers became smaller, software designed to support clinical functions for pharmacy, clinical laboratory, patient registration and billing began to proliferate. The disadvantage of these health information systems was their department-specific functions – they were not accessible by other departments.
The first attempt at a total, integrated health records system was implemented in a gynecology unit at the University Medical Centerin Burlington, Vermont in 1971. Based on the problem-oriented medical record, the system was patient oriented – all disciplines included in care made notes in the record to provide an overview of care to see the relationship between conditions, treatments, costs and outcomes.
Acceptance of the Problem Oriented Medical Information System was not widespread due to resistance to share information across disciplines. Although the idea for collaborative care was presented in the 1970s, the acceptance of collaboration and enhanced communication supported by a holistic health record system did not take place until the 1990s — with the advent of managed care.
The introduction of diagnosis related groups (DRGs) and data required for reimbursement increased the need for hospitals to pull detailed information from clinical systems as well as financial systems to ensure claims payment.
Because personal computers and widespread health-related software applications had grown in popularity, hospital information technology (IT) staff were tasked with the responsibility to integrate multiple, disparate systems. As network solutions were developed, IT departments were able to connect financial and clinical systems – for limited functions.
But as technology advanced, in most cases, hospital departments still could not access information outside their own silos – preventing data-sharing from disparate system.
The introduction of the master patient index (MPI), a database of patient information used across all the departments of a healthcare organization in the 1980s laid the groundwork for initiatives such as The Indiana Network for Patient Care (INPC), the foundation for today’s Indiana Health Information Exchange. In 2017, the health information exchange (HIE) leverages an internally developed MPI that includes 100 hospitals, representing 38 health systems; 12,000 practices with over 20,000 providers; 1,100 Veterans Administration sites and 12 million patients.
As hospitals continued to merge into larger health systems and to acquire individual physician practices, the increased need for interoperability that supported data-sharing grew.
The importance of integrated electronic health records (EHRs) to enable providers to make better decisions grew, and more hospitals and physicians implemented them to reduce the incidence of medical error by improving the accuracy and clarity of medical records. In his 2004 State of the Union Address, President George W. Bush called for computerized health records – the beginning of the electronic health record (EHR) revolution.
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