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This second issue of the Journal features electronic health records. It's worth reminding ourselves of the roles of medical records. Physicians view medical records as management reports with supporting data. Peter Drucker, the noted management consultant, writes that he once consulted for a business enterprise that was drowning in paperwork. His counsel was to halt all management reports for two months. At the end of this period, he advised reinstitution of only those reports that the managers couldn't do without.
Drucker's advice forms the basis for a provocative thought experiment. Would we redesign a medical record system that would look anything like the fragmented office, hospital, and patient information we have now? I doubt it.
Our records take the form of Problem Oriented Medical Records, as developed by Laurence Weed in the 1960's. (Weed LL, Medical Records That Guide and Teach. N Engl J Med. 278: 593-600, 1968.) The SOAP (“Subjective data, Objective data, Assessment and Plan”) note-based system that he described, works for teaching (most medical students and trainees adopt it well), and for episodic care.
For chronic conditions—when a patient has multiple problems with input by multiple providers over time—the Weed system poorly meets our information needs. Oncologists have a developed a “work around.” We use a flow sheet, which uses a column-and-row format to record drug administration data, relevant laboratory, toxicity and symptom data, and disease status, all with an associated date. A major flaw is the flow sheet's poor capture of our interpretation of what the patient tells us, and our thinking about the solutions to problems. For practical purposes, we are in danger of losing these data.
The medical record also serves as a communication tool. When we place orders for tests, procedures, consultation requests or for medication administration, we communicate both to the actual provider of the service and to other physicians. Finally, the medical record is the second layer of communication to third-party payers. For their purposes, it documents what was done, why it was done, and when. The record also provides evidence should a dispute result from the episode of care, whether the dispute arises concerning issues of reimbursement or surrounding liability for an outcome. Sadly, it is this latter concern that often drives the completeness of our record keeping.
The patient—who should be our primary customer—does not directly participate in medical record creation. Our interview with Dr. David Brailer, President Bush's choice to lead the Office of the National Coordinator for Health Information Technology, makes it clear that the government considers the consumer—our patients—to be a major stakeholder in forming the future health record.
We introduce several new features in this issue. A series of interviews with successful clinicians begins with Merrick “Mike” Reese, who is recognized as one of the organizers of US Oncology and its predecessors. We will interview a broad range of clinicians who have organized successful clinical organizations of many sizes. Our second introduction is “What Our Leaders Are Reading” where we will feature that must-read article that has stuck in one of our leaders' minds.
Our feature story examines the electronic health record, and is written by one of ASCO's leads on this initiative, Ed Ambinder. Our original research articles include a submission by Mark Green and his colleagues from the Network for Medical Communication and Research (NMCR) who share data derived from their case discussion-based marketing meetings. In these one-day meetings, attendees' responses to hypothetical cancer cases are recorded and displayed before expert discussion. Green et al tabulate the responses from two lung cancer cases, and discuss the audience's responses in the context of current level 1 evidence. The Journal's outside reviewers considered this to be a piece worth your attention. (Disclosure— I have received honoraria or salary for continuing medical education offerings from NMCR, ASCO, and the University of Michigan).
Finally, we bid farewell to Deborah Whippen from our masthead. Deb is completing her seventeenth year career of service to ASCO, where she started in the editorial office of the Journal of Clinical Oncology. Deb also had a major role in nurturing ASCO.org, ASCO's award-winning Web site, and its spin-offs. We will miss her energy and enthusiasm for start-up, foundling operations, and we all wish her well.