Medical records are something patients take for granted, but they are in many ways a modern invention. Modern medical records have only been around since the 1920s, first in paper form. And now, almost 100 years later, the next iteration is taking place as medical records move to electronic format.
The First Western Medical Records
Some of the earliest “medical records” in the West were actually kept by astrologers, or “astrologer-physicians.” Medical astrology, also known as iatromathematics, assessed people’s health by connecting various parts of the body, physical organs, diseases, and emotional states with the planets and stars.
Simon Forman and Richard Napier were two astrologer-physicians who kept copious notes on their consultations. These “casebooks” date from 1596 to 1634 and are considered to be the most comprehensive group of medical records kept in the West prior to 1700.
These medical astrology casebooks have been digitized and can be searched online. Some of the entries would be considered unorthodox today. For example, Napier attempted to communicate with archangels using dice throws. The angelic messages he felt he received about his patients’ health were recorded in his casebooks.
Other entries might include astrological chart info, a “judgment,” which was a combination of astrology and prognosis, and description of a prescribed “sigil.” The sigil might be a bracelet, ring, or piece of jewelry that was decorated with magical symbols designed to ward off evil spirits and black magic or harness spiritual powers.
While the average paper of records left by these early “physicians” may seem like nonsense to many Western skeptics today, Forman and Napier were at least thorough. Many early medical “records” consisted of simply notes on scraps of paper, with some exceptions. Theodore de Mayerne, from 1603-1653 kept copious records, including some that were elaborate narratives complete with sketches.
The Rise of the Modern Health Information Management Industry
It was in the 1920s that Western medical doctors realized that keeping paper health records would help in diagnosis and treatment.
According to Rasmussen College: “The ACOS standardized these clinical records by establishing the American Association of Record Librarians, a professional association that exists today under the name American Health Information Management Association (AHIMA). These early medical records were documented on paper, which explains the name ‘record librarians.’”
The 1960s and 70s brought new advancements in medical record keeping, with the advent of the modern computer.
Back then, however, computers were not networked like they are today through the Internet. Furthermore, computers were extremely expensive. This limited the use and utility of electronic medical records, as they could generally only be kept on-site and not shared easily. The expense also meant that only the largest healthcare facilities could afford electronic patient records.
Still, over time, computerization worked its way into healthcare. Often it was piecemeal, such as using computers as a way of registering patients, which became especially prevalent in the 1980s. These systems, however, were still hampered by a lack of interconnectivity.
Since 2000, and the rise of the Internet, great advances have been made in electronic medical records. These systems are often called EMR (Electronic Medical Record) or EHR (Electronic Health Record) systems. Today, chances are, your local hospital or healthcare provider is using some sort of electronic system to manager your health records.
This acceleration is due, in part, to federal legislation passed in 2008 requiring 70% of primary care providers to use electronic medical records by 2014.
AI and the Future of Medical Records
The likely next step for medical records in the West is the adoption of artificial intelligence to help with patient care and management. Already, AI companies are working on solutions to help healthcare providers, though many of these initiatives are designed to help with billing and patient management outside of specific diagnoses.
In the future, however, AI will likely screen patient medical records to look for patterns and danger signs. Some of the findings might be used to help individual patients by predicting possible problems before they start. The AI might also be used to analyze populations to notice trends and identify potential health epidemics before they gain too much traction.
Paper Health Records: Now a Thing of the Past
While your local doctor most likely still keeps some paper records, very soon almost all your health information will be maintained in computerized form. You may not even have to fill out any “paperwork” when arriving at the doctor’s office. Instead, you may be asked to mark some items off on a computer tablet. Already, some hospitals are using tablets instead of papers to obtain consent signatures from their patients. With these inevitable changes, paper medical records will simply become interesting historical documents in the future.