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Have You Thought About Your Health Story?

In the near future, the ability for one to read and comprehend his or her own personal health record can and will make a difference. People are unique; their health record should be too
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Probably not, but you should. The onslaught of efforts to digitize our health system are bound to have a profound effect on the future of health care. More so, it will have a direct impact on the manner in which you, the patient, interact with not only your physician, but also the role you play in preserving your health and well-being. As such, the ability for you to read and comprehend your personal health record can and will make a difference. How do I know this? I've been a practicing cardiologist for 26 years and immersed myself in the futuristic digital medical record endeavor far before Barack Obama became our President.

The written patient medical record had its birth in the 19th century and as such, has remained almost entirely unchanged for well more than 100 years. During this time, literally everything else in medical care has evolved. With the computer now making inroads into the patient medical record, just as it has entered every other aspect of our lives, the patient has a tremendous opportunity before them to engage some of the more technologically novice physicians about their plans for health care IT adoption. As a patient, it's crucial that you understand where on the adoption curve your doctor is in relation to embracing burgeoning technology. Your doctor's adoption of critical health care IT will not only improve in-house productivity, it will also enable patients to become more active participants in the care process.

Working in hospitals that have made the big switch, and a practice that was an early adopter of an outpatient electronic medical record (EMR) system, I have experienced firsthand the benefits and challenges that come with taking what is a "leap of faith" and completely changing not only the documentation of care, but the very mechanisms by which care is provided and communicated. The advantages are powerful and worth both the challenges and pain involved in the conversion. Still, change is challenging, especially when you're working in a high stress environment in which people depend on you to make life or death decisions.

Getting everyone in the health care environment on board to learn and support such a system is very demanding, and there are many examples of such implementations failing outright. Training, and getting "buy-in" from mid and late career physicians can be an especially daunting struggle. Ultimately, however, the future of care is dependent upon these changes.

Having said this, a major issue in the transition from paper to electronic medical charts is the physician progress note. From the outset, we need to agree on the critical importance of such notes. It is necessary to tell a patient's story, and to assess the significance of that history. At this time, it simply is unrealistic to think that all healthcare givers will develop the typing skills needed to function adequately in this environment. At best, it will require a full generation of doctors, nurses, technicians, and therapists to come and go before that is as ubiquitous a skill as handwriting is now. It is clear to me that the answer to many of the physician challenges that surround electronic medical record adoption and full patient utilization of these records lies in the use of voice recognition software.

Electronic health records coupled with voice recognition technology allows me to document in the chart while I am seeing the patient. The note is often created with the active participation of patients and family members; and is then finished at the end of the patient encounter and is faxed to the referring doctor. Additionally, a copy is printed out at the checkout desk and handed to the patient as they leave the office. The notes are error-free for the most part, and are immediately available in the chart. There is no reading, correcting, signing, and mailing to be done. Most importantly, the notes can be highly descriptive, capturing not only the raw facts, but the nuanced details that are unique to that patient.

You're unique; your health record should be too

It's only by joining electronic health record technology with voice recognition that we can ensure patients are able to fully understand and participate in the digital care process. Moreover, this coupling will allow physicians full access to a patient's story and enable them to base their decisions on both their knowledge of medicine and on the history of that specific individual.

Dr. Steven Schiff is a practicing clinical cardiologist for 26 years, and Medical Director of Invasive Cardiology at Orange Coast Memorial Medical Center, in Fountain Valley, California. He is also the Chair of Medical Infomatics for the hospital.