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Patient Records at Mayo Clinic: Lessons Learned From the First 100 Patients in Dr Henry S. Plummer's Dossier Model

2008; Elsevier BV; Volume: 83; Issue: 12 Linguagem: Inglês

10.4065/83.12.1396

1942-5546

Christopher L. Camp, Rory L. Smoot, Theofilos N. Kolettis, Cornelius B. Groenewald, Susan M. Greenlee, David R. Farley,

Digital Imaging in Medicine

For more than a century, physicians at Mayo Clinic have been assigning “clinic numbers” to their patients and logging all data under each patient's unique number. The first patient enrolled in this system was assigned the number 1, followed by 2, 3, 4, and so on. To date, nearly 7 million clinic numbers have been assigned to as many patients at the Rochester, MN, site alone; the vast majority of their records are now available electronically. Physicians, medical students, and other allied health staff have access to these records, and consequently, this system for managing health care records has greatly enhanced and streamlined the care administered to patients. This patient record system has also greatly facilitated research, outcome tracking, and the transfer of care from one physician to another. At any time, a physician may access any other physician's notes from any department on any of their patients, a task made considerably easier by the adoption of the electronic medical record. Large groups of patient files that meet certain criteria can be retrieved for purposes of research, review, and discussion. The following are the results of an analysis of one such group, the first 100 patients enrolled in the medical records system at Mayo Clinic. After approval from the Mayo Clinic Institutional Review Board, the complete medical files of the first 100 clinic numbers (001-100) in the Mayo patient record system were reviewed. Each of these files represents a patient who first presented to the clinic within 5 days of one another (July 19-July 24, 1907), and all the patients in the set were assigned consecutive clinic numbers. In the chart review, special attention was paid to the surgical procedures, medical management, and patient demographics of this group. Five (5%) of the 100 charts were missing. The remaining 95 patients ranged in age from 4 days to 68 years on initial presentation (mean age, 36.2 years). Females comprised the majority of the cohort (n=58 [61%]). Of the 86 patients who specified their state or country of residence, 40 patients (47%) listed Minnesota as their home state, while others came from as far north as Canada and as far south as Alabama (Table 1). Patient occupation was most commonly listed as “farming” (Table 1). Other occupations in this 1907 cadre included stereotyper, US marine, saloon keeper, real estate agent, minister, stonemason, bottler, butcher, baker, and horse harness maker. Whether the out-of-town patients were referred to specific physicians at Mayo or were referred to the clinic in general is unknown from the patient records. However, the records do indicate that 43 (45%) of the 95 patients were sent to Mayo Clinic by a physician from another institution.TABLE 1Patient DemographicsaData are given as No. (%) of patients unless otherwise indicated.Age Minimum (d)4 Maximum (y)68 Mean (y)36Sex Male37 (39) Female58 (61)Occupationc83 Patients listed an occupation. Farming39 (47) Sales7 (8) Homemaking4 (5) Teaching4 (5) Banking4 (5) Student3 (4)Residenceb86 Patients provided residence information. Minnesota40 (47) Iowa17 (20) South Dakota7 (8) North Dakota6 (7) Wisconsin5 (6) Illinois2 (2) Montana2 (2) Kansas2 (2) Missouri1 (1) Arkansas1 (1) Alabama1 (1) South Carolina1 (1) Canada1 (1) Not listed9 (10)a Data are given as No. (%) of patients unless otherwise indicated.b 86 Patients provided residence information.c 83 Patients listed an occupation. Open table in a new tab A total of 106 medical diagnoses were assigned to the 91 patients having complete (and legible) records (Table 2). Obesity was not mentioned in any chart, and only 1 (1%) of the 95 patients was classified as diabetic, possibly because diabetes was such a fatal disease before the discovery of insulin. At least 16 (17%) of the 95 patients were designated as having some form of neurosis (eg, “neurasthenia,” “neurosis,” “extreme neurotic”). In some records, this notation was listed in the “Diagnosis” section, whereas in other charts, it was included in the “Objective Symptoms” section. The most commonly documented laboratory test performed in this set of patients was a urine examination: 26 patients (27%) had urinalysis results recorded in their chart. Numerous records included blood cell counts and the results of “other” blood tests and radiographic examinations. Other diagnostic procedures documented in the charts of these patients included eye, ear, musculoskeletal, sinus, and neurologic examinations.TABLE 2Common Medical Diagnoses (N=95)DiagnosisNo. (%) of patientsAcute/chronic appendicitis15 (16)Gallbladder disease10 (11)Goiter/thyroid disease9 (9)Kidney failure6 (6)Myocarditis/heart disease5 (5)Hernia5 (5)Ulcer3 (3)Stomach cancer2 (2)Sinus infection1 (1)Stroke1 (1)Cleft palate1 (1)Otorrhea1 (1)Peritonitis1 (1)Pleurisy1 (1)Various forms of neurosis16 (17) Open table in a new tab Although the charts consistently listed a chief complaint, objective symptoms, subjective symptoms, and a diagnosis, very limited data are available regarding the specific treatment provided to these patients. Most surgical interventions were recorded on the back of the charts, butno space was designated specifically for medical interventions. In most charts (n=87 [92%]), initials or names were scribbled in a blank area at the top; we think these notations indicated the primary medical physicians who consulted with the patients. Dr Henry S. Plummer's name or initials were found on 37 (39%) of the charts, and Dr Herbert Z. Giffin appeared to have cared for 33 (35%) of the patients. Other physicians listed in the patient files were Drs William F. Braasch, E. Starr Judd, Justus Matthews, and Albert P. Maschgar. The first 3 patients in the records system had medical diagnoses of tumor, anemia, and aphasia, respectively. The first surgical patient, patient No. 004, was a 48-year-old woman who presented on July 19, 1907, with right upper quadrant pain and tenderness. Nearly 2 months later, on September 15, 1907, she underwent a cholecystectomy and was noted to have had some “pancreatic involvement.” Of the 95 patients, 32 (34%) had surgery during or shortlyafter their initial visit. Five patients (5%) had 2 surgical procedures each. Operations most commonly involved appendectomy (for chronic and acute appendicitis), cholecystectomy or cholecystotomy, thyroidectomy, and hernia repair (Table 3).TABLE 3Surgical Cases (N=37)OperationNo. (%)Appendectomy12 (32)Cholecystectomy/cholecystotomy6 (16)Thyroidectomy5 (14)Hernia repair5 (14)General abdominal exploration2 (5)Round ligament shortening2 (5)Partial hysterectomy1 (3)Perineorrhaphy1 (3)Excision of varicose veins1 (3)Not described2 (5) Open table in a new tab Without complete certainty of diagnoses preoperatively, some operations were exploratory in nature (n=3 [3%]), and occasionally (n=3 [3%]) the diagnosis was changed intraoperatively to disorders such as pyosalpinx, tuberculous peritonitis, or cholecystitis. More than 1 incision was performed in several patients, usually those with abdominal pain in whom exploration of both the gallbladder and the appendix was completed. Although only 32 (34%) of the 95 patients underwent surgical treatment on their initial visit, another 43 patients (45%) had operations performed at Mayo on later dates (total operations, 86). Two patients (2%) had at least 10 operations documented in their files. Only 8 (25%) of the 32 initial surgical patients had operative pathology reports included in their files. The operating surgeon was not listed in the operative reports or charts of any of the patients undergoing surgery. All 95 patients are now deceased. The cause of death was noted in 5 patient records (5%), 2 (2%) of which included an autopsy report. No follow-up data from 1907 were available for any of the 95 patients (including short-term surgical outcomes, dismissal dates, or dismissal summaries). What distinguishes these 95 patients (100 patient files) from every other patient group encountered in any medical clinic? On the basis of their demographics, medical diagnoses, and surgical needs, not much. In addition, the criterion used to define this group was not related to their medical presentation, treatment, or outcome. The defining characteristic of this group of 100 patients is that they were entered into the Mayo Clinic medical record system between Friday, July 19, and Wednesday, July 24, 1907. They were assigned clinic numbers 001 through 100 and mark the birth of the patient record system that was createdand implemented by the genius of Dr Henry S. Plummer more than a century ago. Only 6 patients (6%) were entered on Friday, July 19 (suggesting that the system was implemented late in the day), 2 (2%) on Saturday, July 20, and none on Sunday, July 21. Most of the charts were entered on Monday and Tuesday (36 [38%] and 48 [51%], respectively), and 3 (3%) were entered on Wednesday. By all indications, this appeared to be a fairly typical volume of patients seen at the clinic during that era (35-50 patients per day). As for the 5 charts (5%) that were missing (Mayo Medical Archives, Fall 2008), it is most likely that appointments were made and clinic numbers were assigned, but the patients did not come in for their appointment. In 1907, the Saint Marys Hospital staff included Dr William W. Mayo as the consulting surgeon and Dr Augustus W. Stinchfield as the consulting physician. Drs William J. and Charles H. Mayo were attending surgeons, and Drs E. Starr Judd and Emil H. Beckman were junior surgeons. Drs Christopher Graham, Henry S. Plummer, William F. Braasch, and Herbert Z. Giffin were the attending physicians, for a total of 5 surgeons and 5 physicians. The remainder of the hospital staff included 4 clinical assistants, 3 pathologists, 3 interns, an artist, and more than a dozen other allied health employees.1Eighteenth Annual Report of Saint Marys Hospital; Rochester, MN; 1907.Google Scholar In 1907, the total number of operations performed at Mayo Clinic was 5523.1Eighteenth Annual Report of Saint Marys Hospital; Rochester, MN; 1907.Google Scholar As the Mayo medical practice grew at a dramatic rate in the early 20th century, the demands for a patient record system that could handle the growing clientele were increasing rapidly. Dr Plummer was dissatisfied with the original record system, in which each physician kept his own notes in his own preferred locations, and obtaining old charts was exceptionally cumbersome and time intensive. Feeling a social responsibility to the many medical specialists who frequented Mayo Clinic for educational purposes, Dr Plummer asked Dr William J. Mayo for permission to develop a new and more efficient system that would better facilitate both education and patient care. After considerable research of record systems at other medical centers, Dr Plummer was not impressed and turned to business and industry for his inspiration. After more than a year of research, he developed the dossier model that is the basis for the medical records system still used at Mayo Clinic today.2Clapesattle H The Doctors Mayo. Mayo Foundation for Education and Research, Rochester, MN1990Google Scholar Under the new system created by Dr Plummer, all patients entering the clinic were registered and assigned a serial number on their initial visit. All the information pertaining to each patient was placed in an envelope bearing his or her personal number, and the envelopes were kept in a single, centralized location. As patients returned for subsequent visits, they retained the same number that was previously assigned, and all new information generated was entered into the original chart. These complete histories were available to physicians immediately on request, and when they were removed from the central housing location, a charge card indicating the exact date, time, and person who removed it was put in its place. This enabled physicians and other staff to locate patient files quickly, even when they were being used by other physicians.2Clapesattle H The Doctors Mayo. Mayo Foundation for Education and Research, Rochester, MN1990Google Scholar These simple charts (FIGURE 1, FIGURE 2) remained in use until 1930, when a longer, modified version referred to as the master sheet was implemented. While handwritten records placed in manila folders gave way to folded registries in plastic sleeves, and eventually to an electronic medical record, the simplicity of hospital records in 1907 isastounding. Most notes were only a few sentences long (Figure 1). Operative notes were typically no more than a single sentence (Figure 2, bottom line), and pathology reports rarely gave more than a diagnosis (Figure 3).FIGURE 2Back of 1907 patient chart documenting objective symptoms and operative note.View Large Image Figure ViewerDownload (PPT)FIGURE 31907 Pathology report.View Large Image Figure ViewerDownload (PPT) Dr Plummer was arguably one of the greatest medical innovators of his time. His contribution to the modern medical record system is one of the most significant and longest-lasting contributions to patient care in the history of medicine and may mark the true beginning of Mayo Clinic. Although it took place 100 years ago, his work with simple, well-organized paper charts is not far removed from the high-tech, electronically driven world of medicine in 2008.