Primary Care Patient Records in the United Kingdom: Past, Present, and Future Research Priorities

摘要

This paper briefly outlines the history of the medical record and the factors contributing to the adoption of computerized records in primary care in the United Kingdom. It discusses how both paper-based and electronic health records have traditionally been used in the past and goes on to examine how enabling patients to access their own primary care record online is changing the form and function of the patient record. In addition, it looks at the evidence for the benefits of Web-based access and discusses some of the challenges faced in this transition. Finally, some suggestions are made regarding the future of the patient record and research questions that need to be addressed to help deepen our understanding of how they can be used more beneficially by both patients and clinicians. Keywords: primary care, access to records, medical records, computerized recordsA Brief History of the Medical RecordThe history of medical records can be dated back as far as the Edwin Smith papyrus of 1600 BC, which describes 48 surgical case histories and was most likely written as an Egyptian surgical manual [1]. Later examples include the case histories of Hippocrates from around 400 BC [2] and medieval Islamic texts from around AD 925, which were largely adapted from Graeco-Roman case histories [3]. Throughout the centuries, medical records were mainly used for teaching purposes [4], and the popularity of cadaveric dissection in the 17th century focused on the use of case histories for the teaching of anatomy [5]. By the 1700s, the keeping of case history books by physicians was becoming more commonplace [6], and medical centers were keeping increasingly detailed patient records toward the end of that century and into the 1800s [7,8]. In the late 1800s, attempts were made to control the content and quality of hospital records for insurance and medicolegal purposes [7], but it was common at this time for physicians to keep their private notes separately to aid patient care [4].In United Kingdom, Lloyd George’s National Insurance Act of 1911 made it compulsory for employed men aged 16-70 years to take out health insurance, and for general practitioners (GPs) providing their care to keep a written record of these patients [9]. While the content and layout of the record were not stipulated, their size was determined by the tin storage boxes provided by the government at that time [10]. These metal boxes were later replaced by envelopes, but the size of the primary care record persisted after the introduction of the National Health Service (NHS) in 1948 [10]. Early criticisms of the format of general practice records focused on the inconvenience caused by the small size of the envelopes, and the absence of a separate problems list [10]. To overcome these problems, there were calls for primary care surgeries to change to records in an A4 format in the 1960s and 1970s, but these failed to materialize [10]. Such concerns were soon to be made redundant by the introduction of computerized records systems [9].Transition to Electronic RecordsThe history of computerized records in general practice can be traced back to Exeter in 1970 when John Preece became the first GP to use a computer in the consulting room [11]. The first government-sponsored electronic records system involved a small pilot by the Department of Health in Exeter in 1972 [9]. Ten years later, the government-sponsored “Micros for GPs” involving 150 UK practices, laying the foundations for further innovations [9]. In 1987, 2 private companies began offering computer systems to general practices free of charge with a plan to offer anonymized data to pharmaceutical companies to recoup their initial investment [11]. These schemes were hugely popular with GPs and this, coupled with remuneration changes in 1990, resulted in an exponential growth in the number of GP practices using computerized systems [9]. While <5% of GP practices used electronic records in the early 1980s, this increased to 80% in 1992 as government incentives continued [9] and by 1996, 96% of general practices used computerized record systems [11].Evolving Functions of the Electronic RecordWhile the functions of the paper-based patient record expanded slowly over the centuries, the computerization of medical records in primary care has opened up a wealth of additional functionality. The functions of the electronic patient record can be roughly categorized into clinical, administrative, and statistical, although there is some degree of overlap. The electronic record continues to be used primarily as a clinician’s aide memoir, enabling primary care staff to see what was discussed at previous appointments or refer to a list of patients’ current and previous medical problems. Clinical tasks, such as prescribing, have become easier, safer, and more cost-efficient as electronic record systems can flag allergies, contraindications, potential drug interactions, and suggest lower cost-generic alternatives. So