Design a standardized form for all medical reporting

One single, deceptively simple idea that would vastly improve medical care in this country by immediately streamlining all medical communication.

Design a standardized form for all medical reporting.

Scope of the problem: Despite my exclusive use of an electronic medical record, I still receive dozens of medical communications on paper every day. So be it. Until we get to the utopian ideal of a nationally interactive medical record system, we’re stuck with dead trees. I get that. I handle it by scanning each report or letter and incorporating it electronically into my record.

Here’s my issue: basic data such as the patient’s name, date of birth, and date of service appear in different places on every form. X-ray reports from one hospital have the name at the top, DOB under that, service date right above the report. Another hospital’s reports have the date of service at the end of the report narrative. Lab reports look completely different. As for letters from consultants, Gd help me! Some only mention the patient in the first paragraph of the letter, with no birth date to be found. Some aren’t dated. Letters generated by one EMR have all the information I need in the upper right; another company’s letters have it on the left. Lord only knows where the date of service can be found.

Banking has long used standardized forms for things like checks. Despite always having the same essential information in the same basic places, they can still be personalized infinitely. A couple of decades ago, all the medical insurers (including Uncle Dr. Sam) got together and agreed on a uniform claim form. (Granted their Explanation of Benefits forms are still all over the map, meaning my office manager has the same hassles trying to post payments as I do finding the data I need in the documents I upload, but I digress.)

All I ask is that every medical report have a uniform heading, with spaces for the patient’s name, birthdate, and a date for the document which should default to the date of service. Other useful pieces of information (for which space could be allocated, even if left blank when unnecessary — like an insurance claim form) could include the physician, the medical record number (used mainly for institutions), location, procedure, etc. It would be nice if the body of the reports followed suit, but I have no problem leaving it with one large content field. Tables for lab results would be nice. Once you design it for paper, frankly it becomes child’s play to adapt it for electronic use, which would be a giant step towards a universal EMR.

Just think, if every single lab report (from every lab), every x-ray report, every procedure report, every referral letter and consultant’s report, every medical document had exactly the same identifying information presented in exactly the same format every time, how much easier it would be to keep it all straight.

I wouldn’t even have a problem with this as a government mandate. After all, you have to use specific government forms to file your taxes, apply for a drivers license, register to vote, etc.

Best of all, it wouldn’t even be terribly expensive. The main issue would be re-programming all the electronics to present the data in the new, agree-upon uniform format. Of course that’s probably why it will never get done: everyone think’s their way works just fine for them, and besides, since there’s so little money to be made, no one will be able to make a killing off of it. Then again, streamlining and simplifying medical communication could prevent other kinds of killing as well. And that would be a good thing.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

Comments are moderated before they are published. Please read the comment policy.

  • Margalit Gur-Arie

    I love this idea. It is so simple and could be so helpful to so many people, but chances are slim to none that it will ever be implemented. Yes, there is no money in it for “entrepreneurs”, but another problem is the current government obsession with structured data, big data, and over-engineering of information exchange. None of those things are in working condition and by the most optimistic estimates, it will take years to get to the holy grail, if we ever do. In the interim, nothing short of perfection seems to be good enough….
    (more here )

  • Ole Reidar Johansen

    It’s called XML.

  • Tim Richardson, PT

    Can a standardized claim form capture enough data for each sub-specialty?

    As Dr. Gur-Arie mentioned, each data field needs to be structured so that it can be arrayed in a database. Easy enough for HgA1c or BP, but what about cognitive, social, historical and other “soft” data points?

    Is narrative data capture an option?

  • W Joseph Ketcherside, MD

    He’s not asking for a form that captures all the medical information on the patient. He’s just asking if we could manage to put the patient’s name in the same place on each report. Pretty sure that would work for each sub-specialty.

    This will never happen because the person who generates the report doesn’t consume it and so doesn’t care in the least how it works for the recipient. It works great for them, since it fits in the fax machine,

    There is already a nice standardized report format for sending information between visits called a Continuity of Care Document but few people use it. And the patient’s name is always in the same place.

  • Jonathan Govette

    Hello Lucy, great article, lets connect soon

  • Edward Winslow

    Great Idea.
    I agree with Dr. Ketcherside. This shouldn’t be “Hard”

    There could be space that is not structured for a Letterhead. then some of the things we all need:
    Name (First Last); Birthday (since we are in the US, the form would be MM/DD/YYYY); Date of Service (also MM/DD/YYYY) Ideally in the upper left corner right under the letterhead. Could also be preceded by “Re:” if that was what we all agreed to.
    It would also be nice to have a field for the type of report (Consultation – Cardiology for example; Radiology: Plain X-ray of xxxx; CT of xxxx; MRI of xxxx; and a few others – not too complex though; Laboratory report: xxxx (SMA-xx; BNP; A1-c; pick from the 25 most common and then have “special study” for all the rest.

    Then could have a narrative or other type of general report. In the future “structured reporting may help make these even more readable)

    All of these fields could be autopopulated either from an EMR or a patient registration or billing software program.

    This should not be hard! If we remember “The Tragedy of the Commons” and work to not have that happen, we should all do better – and this may save us some precious time.

Most Popular