A Longitudinal Medical Record Is Key to Clinical Decision Support

Much of the current focus on the implementation of electronic health records is really a focus on the universal implementation of a longitudinal health record—a comprehensive clinical summary of a patient-based clinical experience, as opposed to the encounter-based, or provider-based records of the past.

As the implementation of EHRs reached out to the ambulatory setting and as hospital-based records were integrated with ambulatory information, the longitudinal record became a realistic possibility. A number of enterprises—the Regenstrief Institute and Partners HealthCare among them—pioneered the development of an integrated, retrievable patient-based record, which could be used for the triad of EHR goals:

1. Tell the patient “story.”
2. Provide a platform for implementation of care guidelines and management, usually in association with clinical decision support tools.
3. Allow for longitudinal, population-based reporting, which can be used for evaluating and optimizing the care delivered and the process by which it is delivered.

It has become clear over the past decade that almost all data relevant to a patient’s ongoing health and its management is universal—including key clinical data such as medication lists, health maintenance activities, clinical pathways and care plans, most laboratory/radiology/ancillary results, and others. Therefore, the only truly care-directing record is a universal one. Episodic approaches don’t provide the breadth of data necessary for an evidence-based approach to quality care.

Further, it has become clear that if this information is going to be used to best effect, it must be collected and stored as “structured” data, using the code base most suited to the data itself (SNOMED, LOINC, RxNorm and others). These data can then be effectively used both for operational priorities—in the delivery of clinical decision support and care-based recommendations—and for reporting and evaluation purposes.

In the U.S. healthcare system, many independent practices and healthcare networks combine to deliver care to individual patients, so an approach that presupposes that all of a patient’s longitudinal, clinical information is in a single data set is challenged, if not fatally flawed. Hence, the focus for the past decade, often with public funding and other support, is to enable the creation of “complete” virtual longitudinal records under the rubric of regional healthcare information exchanges (HIEs) and the prioritization of such data exchange in the meaningful use criteria for EHR incentive funding under the ARRA legislation and subsequent enabling regulations.

Robust, data-rich longitudinal records present enormous opportunities for those of us in leadership positions within healthcare organizations. It is now possible to create and deploy evidence-based content—medication order-based alerts, order sets, clinical guidelines, healthcare maintenance reminders and many others—that “intelligently” targets patient-specific clinical needs with full knowledge of all of the relevant data.

This underlying infrastructure should be usable in many ways: to inform and educate patients, to appropriately organize and deliver medical care, to evaluate the care we are delivering, and make it as efficient and effective as possible, even as we use these data sets in innovative ways to research new modalities and paradigms.

The tasks that these options impose on us are daunting, but future options are truly exciting.

Harris R. Stutman, MD is the Executive Director of Clinical Informatics at MemorialCare Health System in Fountain Valley, Calif.