Introduction to electronic health records

Representing Health Data

When I was in graduate school, I decided that I needed to be more diligent about cleaning the insides of my ears. However, lacking q-tips, I used paper clips instead—a practice nobody recommends, but I was convinced I was qualified to perform as I was a 21-year-old public health student. Of course, this practice quickly turned sour, and I landed in my school’s student clinic with a mild, yet painful, ear infection. The physician that saw me found the whole situation to be rather humorous. We chatted a bit about my studies, she prescribed an antibiotic ear drop, and then turned to the computer to document the encounter in the electronic health record (EHR).

Nearly a year later, during conversations with my fellow coworkers at the school’s oncology clinic, the topic of EHRs was brought up. The University’s policy had recently changed to allow staff to view their own medical records and, as I had access to our EHR, I went ahead and exercised this right. I was horrified to see that the only visit I had with a medical provider was for “REAR PAIN.”

I couldn’t recall a situation where I had experienced rear pain, much less pain sufficient to warrant a trip to the doctor. It was only after further investigation (and a panic-filled half hour) that I realized the encounter was an unfortunate typo of “R EAR PAIN” or right ear pain. It’s amazing how a single space can completely change the meaning of a phrase.

This problem highlights the two distinct types of data ...