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.

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