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At last I got my hands on the landmark article by Nygren and Henriksson (1992). According to Google Scholar this article was sited only 101 times. I believe that the research presented in this article is underappreciated. This qualitative study offers the best insight into how paper medical records are actually used by physicians. This article studied what physicians do in out-patient setting. I find this rare in the study of Medical records in general. Most studies focus on in-patient services. The use of paper medical record (P-MR) by Swedish physicians  was studied. Yet, the findings are generalizable to the places I practiced; Canada and Saudi Arabia.   Seven physicians with at least 5 years of experience were interviewed. These physicians represented the following specialties: general practice (2), cardiology (1), gynecology(1), surgery (1), plastic surgery(1), clinical physiology (1), and psychiatry(1).

With current computer technology, I think it will be difficult if not impossible to have electronic medical records (EMR) serve what Nygren and Henriksson found P-MR serve. Nygren and Henriksson describe P-MR as a clinical tool that supports physicians intellectual tasks and not merely data storage and transfer tool. Nygren and Henriksson found that physicians use P-MR in four distinctive ways: gaining overview, triggering memory, searching for facts, and problems solving.  I will describe each of these.

Gaining overview

This takes place with patients unfamiliar to physicians. The physician usually goes back to a comprehensive note that forms a good start. This could be a recent discharge summary. Then, physicians move forward in time. By the end of this process, physicians will have a fair picture of the patient current condition.

Triggering memory

Nygren and Henriksson  call this triggering of memory-picture. For known patients, physician can remember information beyond what is documented in P-MR by seeing their previous note. A picture with patient situation and given and planned treatment spur into memory. An extreme example, a physician claimed could retrieve this memory-picture by the mere sight of the medical record.

Searching for facts

Searching for specific data, as whether a medication was used in the past or whether physical finding as a cardiac murmur was noticed in the past.

Problem solving

When dealing with challenging problems, physicians use P-MR as a problem solving instrument. Physicians will go back and forth in P-MR gaining overview, searching for specific data while creating hypotheses and then looking for data that will support or oppose these hypotheses. During problem solving, physicians will stumble on facts in the P-MR that could also support or oppose those hypotheses.

With current computer technology it is difficult for EMR to support all above tasks performed by P-MR.  In the pursue of improving EMR, we should not loose sight of the main goal of health care, that is improving health. This may mean, not to try to computerize all types of medical documents. For example, out-patient’s P-MR may best stay in their paper form for now.

In the following post, I will describe some of the experiences developed with computerizing these P-MR. I will illustrate, how EMR can fail their basic functions of storing and transmitting information. This will prove that we are long way from serving above advance tasks.  

Nygren, E. & Henriksson, P., 1992. Reading the medical record. I. Analysis of physicians’ ways of reading the medical record. Computer Methods and Programs in Biomedicine, 39(1-2), 1-12.