Assessment Across the Ages: Implications for the Electronic Health Record

Jennifer Hornung Garvin, PhD, RHIA, CPHQ, CCS, CTR

Introduction

Patients across the globe are using traditional and Western (allopathic) medicine to improve health. At the same time, the records of patients are being modified from paper-based documentation to an electronic format. This technical paper places some of the major medical traditions in historical context, provides a general overview of assessment techniques, and presents implications for the use of various types of medical treatment within the framework of an electronic health record (EHR).

The reasons that individuals use different medical systems to improve health are many, but according to the World Health Organization (WHO), the motivation for patients in developing countries to use traditional medicine appears to be due to cultural preference and the need for accessible and low cost care. In contrast, patients in developed countries appear to use non-Western medicine to address issues of health as either an alternative modality or in a complimentary manner with Western medicine. Further, WHO defines traditional medicine (TM) as forms of medicine, such as traditional Chinese medicine, Indian ayurveda, and Arabic unani medicine, and other types of indigenous medicine. In countries where allopathic medicine is dominant, the terms for TM are "complimentary," "alternative," or "non-conventional."1

While the therapies associated with these types of medical intervention are varied, the assessment of patients has similar components. The use of multiple therapies and their documentation in the medical record is important in light of patient safety, evidence-based research efforts, and the provision of coordinated care to the patient. The recently published e-HIM Practice Standards by the American Health Information Management Association (AHIMA) provide guidance on the Core Data Sets for the Physician Practice Electronic Health Record and the inclusion of data from external sources or other practitioners.2

Overview of the Impact of TM and CAM

TM is used in many countries throughout the world. WHO estimates that usage is rapidly growing, and it provides the following statistics in the report WHO Traditional Medicine Strategy 2002-2005:3

  • Up to 80 percent of the population in Africa uses TM.
  • In China, TM is responsible for 40 percent of all healthcare provided.
  • 48 percent of individuals used CAM in Australia at least once
  • 70 percent of individuals used CAM in Canada at least once.
  • 42 percent of individuals used CAM in the US at least once.
  • 38 percent of individuals used CAM in Belgium at least once.
  • 75 percent of individuals used CAM in France at least once.
  • In Malaysia, 500 million US dollars are spent on TM as opposed to 300 million US dollars spent on allopathic medicine.
  • In the United States it was estimated that the out-of-pocket expenditures for CAM was 2700 million US dollars in 1997.

Concerns About Patient Safety

WHO as well as other organizations within the United States have advocated for the promotion of safe and effective TM/CAM treatments for patients. According to a published report by the Mutual Insurance Company of Arizona (Phoenix), 42 percent of adults in the US reported using alternative therapies within the last 12 months, and 96 percent of those individuals also saw a medical doctor in the same time period, but less than 39 percent discussed their alternative therapies with their medical doctor.4 This report also discusses that an estimated 15 million Americans are taking prescription drugs and herbal remedies simultaneously, which may put them at risk for interactions or side effects. Further, WHO has outlined a framework for action regarding the use of TM/CAM. One of the objectives of the framework calls for the promotion of safety, efficacy, and quality of TM/CAM.

Historical Context

Both allopathic medicine and TM have evolved over many millennia. Allopathic medicine has its roots in Mesopotamia, Egypt, and Ancient Greece. During the Roman era anatomy, physiology, and therapeutics were furthered through the well-known work of the physician Galen. One of Galen's principal ideas was that scientific knowledge of the cause of disease was essential in order to provide successful treatment.5 Allopathic medicine was influenced by the Renaissance, Islamic medicine, and finally by the modern era. The result of this evolution was a standardized assessment method, which comprises a systematic process of working through the body systems, evaluating the history of the illness, and a physical examination. In addition, the physician may obtain specimens from the body to evaluate. From this aforementioned data, an allopathic health practitioner determines a diagnosis and best course of treatment.

In the medical traditions of China and India, medical practice has evolved over several millennia as well, and practitioners also follow a systematic process of assessment. The major difference in the assessment techniques is in what the practitioners assess. In traditional Chinese medicine, the practitioner uses four diagnostic methods: viewing, listening and smelling, asking, and feeling. Viewing involves a general visual examination of the patient with a localized visual examination of the patient's skin, tongue, eyes, nose, and lips. The condition of these areas assists in determining the cause of illness. It is also important to listen to the voice and to listen and smell the breath of the patient. The patient is also asked about their body temperature, excretions, appetite, and bodily responses. Feeling involves determining the pulse and examining various parts of the body. Following this process of assessment, the practitioner determines the classification of disease that results in a treatment.6

Ayurvedic medicine evolved from the medical tradition of India. In this tradition, the practitioner determines the patient's history, undertakes a physical examination (including an evaluation of the patient's general appearance, palpation, and auscultation,) and assessment of bodily fluids. Based upon the findings of this process, the practitioner determines a diagnosis and treatment. Both traditional Chinese and Ayurvedic medicine place the focus of assessment and treatment on the health and functioning of the patient.7

Implications for the Medical Record

Information about patients receiving TM/CAM is documented for assessment of patients when TM/CAM takes place in locations where written records are kept. But the exact content and retention period appears to vary. Certainly as research efforts proceed, it will be important to have written information about the initial status of the patient and the response to treatment at a minimum. There may also need to be standardized data elements so that the efficacy of various treatments for a given disorder can be compared.

In terms of the electronic physician record, it is important that the record contain data elements pertaining to complementary or alternative treatments. It is also recommended that the physician specifically ask about herbal substances and the record list some examples of the type of the types of CAM treatments that are of interest to the physician.8 In the future, if CAM practitioners keep electronic records, it may also be possible to import sections of the physician record from CAM practitioner electronic files, and it may also be important to include patient self-assessed or patient recorded data.

Conclusion

TM/CAM plays a significant role in the health of patients and because of this, it is important to work toward appropriate and consistent documentation of patient assessment and response to treatment. In developing countries this will allow continuity of care and add to evidence-based research. In developed countries documentation of TM/CAM will benefit the patient through coordinated care, alert practitioners about potential treatment interactions, and will facilitate research in TM/CAM.

Endnotes

  1. World Health Organization. WHO Traditional Medicine Strategy 2002-2005. Geneva, Switzerland: World Health Organization, 2002. (This report is available at www.who.int/medicines/organization/trm/orgtrmmain.html ).
  2. American Health Information Management Association. e-HIM Practice Standards. Chicago: American Health Information Management Association, 2003. (This information is available at www.ahima.org ).
  3. Ibid.
  4. Atkinson, W. " Alternative Approach."   Modern Physician 7 (2003), 12:22-23.
  5. Magner, L. A History of Medicine. New York: Marcel Dekker, 1992.
  6. Kit, WK. The Complete Book of Chinese Medicine: A Holistic Approach to Physical, Emotional, and Mental Health. Kedah, Malaysia: Cosmos, 2002.
  7. Magner, L.
  8. Atkinson, W.

Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004