Medical Records: A Historical Narrative

Abstract

The history of medical records is thousand-year-long, with earlier roots in ancient civilizations. Until the 19th century, medical records mainly served educational purposes, later assuming other roles such as in insurance or legal procedures. This article comprehensively describes and reviews the development of medical records from ancient to modern times in Europe and North America, reflecting alterations and adaptations compliant with the mental and technological capabilities of a given period. We searched PubMed and Google Scholar databases to collect pertinent articles. English articles or those having English abstracts were considered. The search terms included “Medical Records,” “Health Records,” “History of Medicine,” and “eHealth” and covered the last hundred years. References were also picked out from the identified articles. Overall, 600 articles were identified, 158 of which were judged thematically relevant. The general conclusion is that medical records undergo a revolutionary change from paper-based to electronic format, which reflects the development of eHealth systems. The migration process to eHealth records involves the use of artificial intelligence (AI) algorithms that streamline medical services by using faster and simpler working methods. AI benefits both patients and providers as it improves patient management and communication among medical centers, spares resources, identifies contamination or infections, and limits health costs. These advantages have become pointedly apparent during the recent COVID-19 scourge.

Evolution of Hybrid Intelligence and Its Application in Evidence-Based Medicine: A Review

“…AI, and more specifically data mining and machine learning (ML) techniques, are now used to process and learn automatically from Big Data [9,10,15]. Currently, the adaptation process to eHealth records must involve AI algorithms to make medical services more manageable and malleable, health prevention-oriented, and cost-effective [7,9]. EBM is evolving accordingly; instead of extrapolating evidence from data obtained from a small number of samples to draw conclusions about the researched population, we are now able to use clinical data coming from the whole population to provide a real-world picture [7,[16][17][18].…”

“…Both medical practice and clinical research are based on patient data. Initially, the major change in patient data collection came from separate files to document collection into folders after patient discharge [ 7 ]. Clearly, records’ content was limited and data were often scattered between wards, clinics, and ambulatories, so finding relevant details was difficult and often relied on the record’s author’s memory [ 7 ].…”

“…Initially, the major change in patient data collection came from separate files to document collection into folders after patient discharge [ 7 ]. Clearly, records’ content was limited and data were often scattered between wards, clinics, and ambulatories, so finding relevant details was difficult and often relied on the record’s author’s memory [ 7 ]. Progressive medical specialization produced more and more specialized health records, which required an increasing quantity of new diagnostic and therapeutic procedures and subsequent specific documentation [ 7 ].…”

“…Clearly, records’ content was limited and data were often scattered between wards, clinics, and ambulatories, so finding relevant details was difficult and often relied on the record’s author’s memory [ 7 ]. Progressive medical specialization produced more and more specialized health records, which required an increasing quantity of new diagnostic and therapeutic procedures and subsequent specific documentation [ 7 ]. Moreover, medical data originate from many different sources, including administrative health data, biomarker data, and imaging [ 2 ].…”

Expanding Quality by Design Principles to Support 3D Printed Medical Device Development Following the Renewed Regulatory Framework in Europe

“…Beyond the vast palette of quickly developed COVID-related devices, the use of digital health technologies was accelerated with electronic-diaries, remote patient monitoring, quick diagnostic kits and wearable devices, such as “accelerometers to track activity, glucometers to track blood glucose levels and devices to monitor heart rates” [ 161 , 162 ]. Telemedicine ™ is becoming increasingly popular in many medical fields including “Neurology, Ophthalmology, Psychiatry, Dermatology, Pediatrics and Allergy” [ 163 , 164 , 165 ], especially in the absence of in-person visits.…”