We take for granted the volume of data collected and stored during routine exams and medical procedures. What is equally remarkable is this data is collected by means ranging from physical palpation by a provider, to highly calibrated machines and software. Technology to disseminate health data has developed alongside the tools to acquire it, although perhaps not at the same rapid clip.
There are three broad ways that health information needs to be handled in order to be useful. It must be 1) communicated/transmitted, 2) interpreted, 3) stored. Some technologies combine more than one feature, others are singular. At BeckonCall, we are obviously interested in the communication of health data. We think a lot about older healthcare communication technologies, and how to make them better. However, it is also interesting to go back and look at various tools to see where those three different functions overlap, as well as just have some fun reviewing how health data has been managed and disseminated throughout history.
Medical procedures were documented thousands of years ago in France, as well as in the fourth century BC in Egypt. The latter is often considered the cradle of medicine. Scrolls have been retrieved describing various ailments and triaging them into one of three categories depending on the prognosis. There is some controversy as to whether the Egyptians really pioneered surgery, but more basic interventions are undisputed. In this way, both written and graphical representations of ancient medicine checked all three boxes. Descriptive text and images - in any era - provide mechanism for communication, storage and interpretation. (Although it may not be the best idea to perform a surgical procedure based on an “interpretation” of French cave drawings. Just a thought.)
Plenty of work documenting medicine exists from Ancient Greece and other cultures. In addition, there has been speculation that “information about bubonic plague was transmitted across Europe by heliograph or bonfires as was information about war and famine.” However, one of the most intriguing sets of records comes much later, from the casebooks of Simon Forman and Richard Napier. Starting in the late 16th Century, the two astrologers recorded 80,000 cases over the course of 40 years. (That’s an average of 5.5 visits per day, for you practice managers looking to compare the throughput of your team in 2017). Their notes include brief and very general descriptions of their patient’s ailments, relatives who were present, and astrological information if relevant. Because of the limited amount of information for any given case, it seems likely Forman and Napier’s records served mostly as storage.
Skipping forward a couple more centuries, communications powered by electricity began to transform society and medicine. In 1831, Henry Joseph demonstrated the transmission of an electrical signal across a mile-long wire, setting the stage for the telegraph’s creation by Samuel Morse a couple of years later. During the Civil War, medical reports and requests for supplies were transmitted by Morse’s invention. More significant was the telephone. The first direct-dial phone came from Almon Strowger in the late 1880s. According to Karen Zundel, unlike the telegraph, “physicians were among the first to adopt [the telephone].” And, obviously, that adoption stuck, as it did throughout the rest of society. The first answering machine came on the scene around 1900, although it didn’t see widespread use for several more decades. For the time being, anyway, physicians were safe from coming in to the office to find a backlog of overnight calls from worried patients.
In the meantime, though, live answering services developed as an outgrowth of the switchboard. It’s not clear exactly what this evolution looked like, but there has been at least some hint that the medical community took early advantage of the service. Thus, medical answering services have long allowed for transmission of medical information, but little more.
Advances in radio communications also played a significant role on the communication of medical data. Starting in the early-mid 20th Century, radios were used by physicians to contact patients in remote locations. Then, during NASA’s heyday in the ‘60s, the agency developed remote monitoring to keep track of astronaut’s health during flights. Zundel suggests that this is really the point at which telemedicine became a notable part of healthcare, and she adds that remote monitoring via television was another significant advance around the same time. Today, radio communication remains a valuable tool for accessing care in developing countries where cell coverage is spotty.
Storage and transmission were also advanced significantly by the photocopier and fax machine. Faxes were first developed in the mid 1800’s, but had to wait over 100 years to reach a point where the technology was broadly accessible. Xerox holds claim to the first commercially viable versions of both, with the photocopier coming on the scene in 1959 and the fax machine in the mid ‘60s. And now, almost 60 years later, we still hear “I need to make a copy of your insurance card” almost every time we enter a doctor’s office. Faxes have been used to transfer records between offices, as well as submit hand-written schedules and notes to on-call answering services.
Fortunately, faxes are being supplanted by web-based tools. (That sentence seems so obvious that it feels strange, almost like a character from Mad Men wandered on to this blog and sat down to write.) Email, scanners, and electronic health record systems have largely obviated the need to punch in a phone number and feed paper through a squealing machine. This is where we finally begin to see a convergence of storage, transmission and interpretation taking place.
Email first took shape in the ‘60s, was first sent via ARPANET (the precursor to the modern internet) in 1971, and came into widespread public use in the late ‘80s and early ‘90s. Medical records were also first conceived in the late ‘60s (a historical theme seems to be emerging here) by Larry Weed. The idea was to create documents that would aid in decision-making rather than simply recording diagnoses, as well as to provide a more comprehensive and interactive story to allow others to review/confirm the original provider’s conclusions. In this way, the EHR could be viewed as a long-distant but still recognizable descendent of Forman and Napier’s medical/astrological case books. (For more on the history of EHRs, see this review by Richard Gillum.)
Larry Weed’s idea of using set templates to record medical information, called structured data, is a key feature of EHRs. However, the medical community is still trying to take full advantage of the concept to help provider faster and more accurate care. Newer software is beginning to take handwritten notes and read it, extracting useful data and putting it into the record where it will be most helpful. Artificial intelligence and “big data” are adding exciting new capabilities to these systems. By digitizing and standardizing record keeping, the hope is that efficiency and quality of care can increase in parallel. Adoption increased dramatically in the first decade of the 21st Century (from 18% in 2001 to 57% in 2011), and continues to rise thanks to newer requirements within the ACA.
And yet, even after more than a half-century, the combined functionality of storage+interpretation for which EHRs were designed remains to be fully realized. A recent article in the Wall Street Journal highlighted the challenge as seen at MD Anderson Cancer Center. The organization is reducing its staff by 5% due to loss in revenue, caused largely by “a drop in physician productivity as the Houston-based hospital began using new electronic health records last year. Doctors took time away from patients to learn the new computerized system, and continue to struggle with it.”
The last major advance in medical communications to note here is the advent of mobile networks. Japan hosted the first cell network in 1979, with the US following four years later. Texting started with a “Merry Christmas” sent in late 1992, and the first text-capable consumer cell phones were released the next year. Now, finally, as adoption of mobile technology took off in the late ‘90s, medical care teams had the ability to send and receive information about their patients in real time. As Blackberry built handsets designed for professionals in the early 2000s with robust text and, later, email, capabilities, healthcare providers became largely untethered from legacy technologies. No more having to stop by one’s desk to check an answering machine or scroll through emails.
Furthermore, mobile technology is integrating communication, interpretation and storage of medical information to an unprecedented degree. And most of that has happened in just the past decade. Startup companies are building tools for remote monitoring of everything from telemetry on sleeping infants to neurological conditions. Data is sent instantly to smartphones or tablets, securely stored locally or in the cloud, and analyzed for patterns or acute incidents (e.g., seizures or a drop in oxygen levels). All of this is carried out under the rules laid out by HIPAA in 1996, which created perhaps the most significant regulatory framework for medical information in history.
Even when technical medical information isn’t involved, smartphones today provide healthcare professionals with a simple, streamlined tool to interact with colleagues. A quick text can be easier than an email, and managing schedules no longer requires the use of fax machines and outside answering services. What used to take several manual steps now only requires a few twitches of the thumb.
We at BeckonCall are clearly invested in advancing technology used for the communication of health information, and we are proud to be part of this long history. We, along with our colleagues and competitors, will continue to find new ways to use the digital revolution to improve the interactions taking place between healthcare providers and their patients.
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Topics: Care team communication