Elsevier

The Lancet

Volume 352, Issue 9137, 24 October 1998, Pages 1375-1378
The Lancet

Series
Design should help use of patients' data

https://doi.org/10.1016/S0140-6736(97)08306-2Get rights and content

Summary

Checklists and other tools help doctors to use published evidence in clinical practice. Two other important sources of evidence, however, are the patient and his or her medical record. This series aims to advance the practice of evidence-based medicine by helping in redesign of medical records, drawing on insights from psychology, information design, and medical informatics; and by promoting changes analogous to those occurring in the medical literature. The four papers look at: the uses of medical records and importance of organising them so doctors can use the data they contain; different methods doctors use to search for data and how design of records can help or hinder these approaches; how we interpret data once found, and how record formatting assists this process; and the issues raised by computerisation of records.

Section snippets

Uses of medical records

Doctors spend a quarter of their working life managing clinical information,5 much of it found in medical records. Medical records consist of handwritten or computer-generated paper or screens viewed on a monitor. More data on patients are now recorded than ever before6 because of increasing rates of chronic diseases, increasing interdisciplinary practice, and greater numbers of tests. Records have different users and purposes,6 but in this series we are interested in their use by doctors as

Difficulties with use of data from records

For various reasons (panel 1) most doctors find it hard to gain a rapid overview of a patient's clinical problems, past results, and treatment from the medical record.7 Many of these problems could be addressed by better presentation of data in records.

The Organisation for Economic Cooperation and Development has stated that “information must not be…presented in such a form or manner as to be misleading”.8 Poor presentation of patients' data can lead to poorly informed clinical practice,9

Better design of medical records

To make the data they contain easier to use, records should be designed to help doctors find relevant information rapidly and interpret it without error. In many instances, record design seems to be determined more by history, arbitrary rules, or non-clinical use (such as legal proceedings) than by the need to support data retrieval and interpretation in the clinic. This state of affairs may arise because the delays and errors caused by bad design are poorly documented and various interacting

What's in a medical record?

Medical records–whether on paper or computer screen– contain sections, each with different kinds of documents, which in turn contain pages with much textual and numerical data, graphs, and pictures. Such documents include progress notes, referral letters, prescription charts, and laboratory reports. Although this arrangement is similar across similar institutions, there are commonly substantial differences in format, length, and content between hospital and primary-care records. There is also

Alternative formats

The many kinds of data included in medical records can be represented by means of seven different formats (panel 2), but currently prose is most commonly used; alternative formats that make data easier to find or interpret are neglected. This raises the question, when is changing the format cost-effective? Panel 2 shows that each format has both strengths and weaknesses. Records are written once but read many times, so people redesigning records must balance the extra effort it may take to

Advantages and disadvantages of record redesign

Redesign of records to use a wider range of more appropriate data formats can lead to faster clinical access to data, reduction in medical errors, access to the patient's lost past history, and facilitation of clinical audit and research. Redesign may also reduce an institution's risk exposure and act as a focus for other quality-improvement activities, such as bringing disparate professional records together and developing care pathways. Good design also has economic benefits for health-care

Examples of improved design

In the radiotherapy summary in figure 1 (top section), the data are organised as dictated and typed, with inconsistent use of date formats and important data hidden in the prose. The dose is given as 42·9 Gy; but 43 Gray is easier for the non-specialist. The alternative format(figure 1, bottom section) is more structured, uses fewer words, and allows clinicians to find data they need–for example, the duration of radiotherapy–more rapidly, and to interpret them more reliably. A classic example

Conclusions

Beyond medicine, a great deal has been learned about how to design information to make it easier to use.22, 23, 24 As explained by Sless,25 “Information design is about managing the relationship between people and information so that the information is accessible to and usable by people”. Organisations ranging from advertisers to public utilities and drug companies employ information designers who combine skills in graphic design, writing, editing, and human factors to make information easier

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