Organizes And Codes Patient Records

The patient record is the chief repository for information concerning a patient's health intendance. It affects, in some way, virtually anybody associated with providing, receiving, or reimbursing wellness care services. Despite the many technological advances in wellness care over the by few decades, the typical patient tape of today is remarkably like to the patient record of 50 years ago. This failure of patient records to evolve is now creating additional stress inside the already burdened U.Due south. wellness care organization as the information needs of practitioners,¹ patients, administrators, 3rd-political party payers, researchers, and policymakers often become unmet. As described by Ellwood (1988:1550),

The intricate machinery of our wellness care system tin can no longer grasp the threads of experience… Too often, payers, physicians, and health intendance executives do not share common insights into the life of the patient… The health care organisation has become an organism guided by misguided choices; information technology is unstable, dislocated, and badly in need of a key nervous system that can help it cope with the complexities of mod medicine.

Patient tape comeback could brand major contributions to improving the health care system of this nation. A 1991 General Accounting Function (GAO) written report on automated medical records identified three major means in which improved patient records could benefit health care (GAO, 1991). First, automatic patient records can amend health intendance delivery by providing medical personnel with better data admission, faster data retrieval, college quality data, and more versatility in information display. Automatic patient records tin can as well support conclusion making and quality assurance activities and provide clinical reminders to assist in patient care. 2nd, automated patient records tin heighten outcomes research programs by electronically capturing clinical data for evaluation. Third, automated patient records can increase hospital efficiency past reducing costs and improving staff productivity.

Several sources back up these conclusions. The GAO reported that an automatic medical tape arrangement reduced hospital costs past $600 per patient in a Department of Veterans Affairs hospital considering of shorter hospital stays (GAO, 1991). Reductions in the length of inpatient stays were also found in other studies of computerized medical records and medical record summaries (Rogers and Haring, 1979). Other investigators constitute enhanced care and improved outcome of care for clinic patients (Rogers et al., 1982) and a reduction in medication errors (Garrett et al., 1986).

The first footstep toward patient tape improvement is a close exam of the users of the patient record, the technologies available to create and maintain it, and the barriers to enhancing information technology. To that end, the Plant of Medicine (IOM) of the National Academy of Sciences undertook a study to recommend improvements to patient records in response to expanding functional requirements and technological advances. ^two This report is the product of the multidisciplinary panel's 18-month study of how patient records can be improved to meet the many and varied demands for patient information and to enhance the quality of patient intendance and the effectiveness and efficiency of health care commitment.

The Study

The idea for this study originated in discussions between staff at the National Institutes of Health (NIH) and IOM. The NIH staff were involved in patient care, instruction, and research and were motivated by the need to brand patient records more useful for all of these purposes. The IOM was considered to be an ideal agent to join the diverse perspectives needed to address a broad range of patient record issues. Thus, the participants at a June 1986 IOM programme development workshop recommended that the constitute deport a study of the patient record in lite of new technologies. Later on, staff of the IOM Council on Wellness Intendance Engineering developed an activity programme for the written report, which was approved by the National Research Council in July 1987. Efforts to enlist adequate fiscal support occurred over the ensuing two years.

The IOM appointed a written report committee in March 1989, and the committee began its deliberations the post-obit September. Among its membership were experts in community and bookish medicine, wellness information services, wellness services research, infirmary services, medical information systems, regulatory functions, and third-party payment.

The Committee'south Charge

In full general, the IOM study committee was charged to examine the bug with existing medical tape systems and to propose actions and enquiry for their comeback in light of new technologies. Specifically, the committee was asked to:

examine the current land of medical record systems, including their availability, utilise, strengths, and weaknesses;
identify impediments to the development and employ of improved record systems;
identify ways, including developments now in progress, to overcome impediments and improve medical tape systems;
develop a research agenda to advance medical record systems;
develop a programme, blueprint, and/or other provisions for improved medical record systems, including a means for updating these systems and the inquiry agenda as advisable; and
recommend policies and other strategies to achieve these improvements.

In add-on to addressing the technological problems in its charge, the committee sought to produce a report that would increase the involvement of all wellness intendance practitioners in improving patient records and health care information direction. Interest of these practitioners in the development of future patient records is required if tape improvement efforts are to run across with success.

Committee Activities

The commission met five times between September 1989 and December 1990. It established three subcommittees—Users and Uses, Technology, and Strategy and Implementation (see Appendix A). The subcommittees, each with approximately 15 members, met at to the lowest degree twice and solicited information from more than seventy advisers, including physicians (in both private practice and academic medicine), nurses, dentists, medical record professionals, hospital administrators, researchers, and congressional staff. Too among these directorate were representatives of patient groups, figurer software and hardware vendors, third-party payers, government agencies, and professional organizations. Each subcommittee prepared a report that was considered, along with the results of a special workshop and several background papers, past the full committee in its deliberations.

Definitions

During its work, the committee used the following specific definitions:

A patient record is the repository of data about a single patient. This information is generated by health intendance professionals as a direct event of interaction with a patient or with individuals who have personal cognition of the patient (or with both). Traditionally, patient records have been newspaper and have been used to shop patient care data.
A computer-based patient record (CPR) is an electronic patient record that resides in a arrangement specifically designed to back up users by providing accessibility to consummate and accurate data, alerts, reminders, clinical conclusion support systems,^three links to medical knowledge, and other aids.
A master patient tape is used past wellness care professionals while providing patient care services to review patient information or document their own observations, deportment, or instructions.
A secondary patient record is derived from the master tape and contains selected data elements to assistance nonclinical users (i.e., persons non involved in straight patient care) in supporting, evaluating, or advancing patient care.⁴ Patient intendance support refers to assistants, regulation, and payment functions. Patient care evaluation refers to quality assurance, utilization review, and medical or legal audits. Patient care advancement refers to research. These records are frequently combined to form what the committee terms a secondary database (e.g., an insurance claims database).
A patient tape arrangement is the fix of components that form the mechanism by which patient records are created, used, stored, and retrieved. A patient record system is usually located within a health care provider setting. It includes people, information, rules and procedures, processing and storage devices (e.thou., newspaper and pen, hardware and software), and communication and support facilities.

A patient record arrangement can exist role of a hospital data system , which typically handles both administrative and clinical functions, or a medical information system, which has been defined as "the set of formal arrangements by which the facts apropos the health or wellness care of individual patients are stored and processed in reckoner" (Lindberg, 1979:ix). A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The fundamental focus of such systems is clinical data and not fiscal or billing data. Such systems may be limited in their scope to a unmarried area of clinical data (e.chiliad., dedicated to laboratory data), or they may exist comprehensive and cover virtually every facet of clinical information pertinent to patient intendance (e.g., computer-based patient record systems).

Written report Organization

The remainder of this chapter discusses the current state of patient tape systems, including their strengths and weaknesses, and the environment of opportunity that exists for implementing computer-based patient records. Affiliate 2 delineates the needs of patient record users and describes how futurity patient record systems tin meet user needs. Affiliate 3 identifies technologies essential to time to come systems and assesses how well existing systems meet hereafter requirements. Chapter 4 describes nontechnological barriers to improving patient records and presents a strategic program for overcoming them. Finally, Chapter v sets forth the commission's recommendations for accelerating the realization of computer-based patient records and suggests an agenda for their implementation and dissemination inside a decade.

The Patient Record

Virtually every person in the U.s. who has received health care since 1918 has a patient record (MacEachern, 1937). Today, nearly people have multiple patient records—one for each health care provider they have visited. Patient records have proliferated to the extent that some medical centers in big metropolitan areas may now each have more than than four million paper patient records (Kurland and Molgaard, 1981). Although at any in one case these records are not all agile, they must be stored for upward to 25 years, depending on state laws (Waller, in this volume). Moreover, a given patient may have more than one record even within a particular institution.^v

Patient records announced in a variety of forms—for example, equally paper; microfilm; a monitor strip; an optical disk; a calculator bill of fare, record, or disk; or a combination of these (Amatayakul and Wogan, 1989). They are created and used well-nigh frequently in health care provider settings such as physician or dentist offices, hospitals, nursing homes, and public wellness clinics; but other institutions such as correctional institutions, the armed services, occupational wellness programs of employers, and colleges and universities also maintain patient health care records (Westin, 1976).⁶

For more than a century, the paper patient record has been the main vehicle for recording patient intendance information (Huffman, 1981). Yet recent years accept seen a tendency toward automation of components of patient records (east.thou., clinical laboratory test results) or certain patient care functions (eastward.g., inbound physician orders for hospitalized patients; Westin, 1976; Gardner and Perry, 1989; Amatayakul and Sattler, 1990). Some hospitals, health maintenance organizations, and physicians' offices now have prototype elements of computer-based record systems .^vii These facilities are still the exception rather than the rule, however, and newspaper patient records, with their sometimes disregarded strengths and frequently cited weaknesses, are notwithstanding the norm for nigh health care providers.

Strengths and Weaknesses of Paper Patient Records

The commission's literature review did not reveal any substantive documentation of the strengths of paper patient records. This result may exist explained in function by the facts that the value of maintaining patient records is widely accepted in the health care customs and that paper is the almost widely used record keeping form. Given the prevalence of paper patient records, the commission noted that support by practitioners for this kind of record keeping should not be underestimated. Time and resource constraints did not permit the committee to survey user attitudes toward newspaper records; however, committee members identified at least 5 strengths of such records from the perspective of record users:

1.: Newspaper records are familiar to users who consequently do not need to acquire new skills or behaviors to use them.
ii.: Paper records are portable and tin be carried to the point of care.
3.: In one case in hand, newspaper records do not feel downtime as calculator systems do.
4.: Paper records allow flexibility in recording data and are able to record "soft" (i.eastward., subjective) data easily.^eight
v.: Paper records tin be browsed through and scanned (if they are non also large). This characteristic allows users to organize data in diverse ways and to await for patterns or trends that are not explicitly stated.

Criticism of current patient records is sometimes sharp. Burnum (1989:484) states that "medical records, which have long been faulty, contain more distorted, deleted, and misleading data than e'er earlier." Pories (1990:47) relates the story of an engineer who was asked to recommend more efficient employ of health care personnel but who instead was "stunned past the disorganization of the medical record and the inefficiencies it imposed on the delivery of care." The engineer concluded that "the redesign of the tape offered the most firsthand and simple approach for medical toll command and for prevention of malpractice" (p. 47).

Pories believes that this situation has not improved and that information technology is not isolated. "No one has a monopoly on the problem: medical records announced to be equally bad and dangerous throughout the land" (Pories 1990:47). He is not alone in his view that patient records frequently lack the features needed for their nearly beneficial utilise. In a recent survey of internists in academic and private do, 63 percent of the respondents agreed with the argument that patient records are condign increasingly burdensome without improving the quality of patient intendance (Hershey et al., 1989).

The weaknesses of patient records, equally described in the literature and in the work of the committee, tin can be subsumed nether 4 chief headings: (ane) content; (ii) format; (3) access, availability, and retrieval; and (iv) linkages and integration.

Problems with Patient Record Content

Patient record information are often missing, illegible, or inaccurate (Tufo and Speidel, 1971; Zuckerman et al., 1975; Bentsen, 1976; Zimmerman, 1978; Fox et al., 1979; Romm and Putnam, 1981; Gerbert and Hargreaves, 1986; Hsia et al., 1988; Pories, 1990). Data can be missing for at least three reasons: (one) questions were never asked, examinations were never performed, or tests were never ordered; (2) the data was requested and provided, just either it was non recorded by the clinician or delays occurred in placing the information in the record; and (iii) the information was requested and delivered but was misplaced or lost. In addition, clinicians, patients, or equipment can all introduce errors into patient records (Burnum, 1989).

Many studies accept examined the quality of patient record content. Table ane-1 presents the findings of several such investigations. The missing information reported in the various studies ofttimes resulted in additional costs of patient care. For case, an estimated 11 percent of laboratory tests in i hospital were ordered to indistinguishable tests for which findings were unavailable to the doc at the time of the patient visit (Tufo and Speidel, 1971).

TABLE 1-ane

Selected Parameters and Findings of Studies of Patient Tape Content.

Although for some records data are missing, in other cases sure data are excessive or redundant (Zimmerman, 1978; Korpman and Lincoln, 1988). The thickness and weight of the records of patients with chronic bug can be imposing, if not daunting, and time constraints may preclude the user from finding and using necessary information. (In one written report of paper patient records, the average weight of a clinic record was ane-one/2 pounds [Rogers et al., 1982].) Other issues related to record content include failure to capture the rationale of providers, lack of standardization of definitions of terminology, failure to describe the patient experience, lack of patient-based generic wellness effect measures, and incomprehensibility for patients and their families.

Problems with Format

Several studies take pointed to patient record formats as a trouble surface area that at times impedes tape use and effectiveness. The 1980 IOM study cited in Table ane-1 institute that the reliability of hospital belch information depended on the full general organization, orderliness, and logic of the medical record. Zimmerman (1978) conducted a survey of physicians who identified poor organization of medical records as a deficiency that contributed to ineffective use. The format of the usual paper record does non lend itself easily to dealing with multiple bug over a long catamenia of time. For example, Pories (1990) noted that the physical grade of paper records (i.e., binders or charts) is often unmanageable; information are fragmented inside the record and not sorted for relevance. Chips (1974) showed that data could be establish four times faster in a structured menstruation canvass than in a traditional paper medical record and that 10 per centum of items in the traditional record could not be found.

Traditionally, patient records are organized co-ordinate to the sources and chronology of data (Feinstein, 1970), although several alternative record formats have been developed. For example, the problem-oriented medical record (POMR) is assembled co-ordinate to the patient'southward problems to back up a more organized arroyo to clinical trouble solving and direction (Weed, 1968). The summary time-oriented tape (STOR) is an outpatient medical record system that consists of a concise summary of a patient'southward clinical data that can be used either in conjunction with the traditional medical tape or by itself (Whiting-O'Keefe et al., 1985).

Problems with Access, Availability, and Retrieval

Record unavailability and difficulties in accessing records when they are available are frequent problems for patient record users (Pories, 1990). Tufo and Speidel (1971) documented in their written report that medical records were unavailable in up to xxx per centum of patient visits. They attributed this rate of unavailability to several possible causes: patients being seen in two or more than clinics on the aforementioned day, charts not being forwarded, physicians keeping records in their offices or removing them from their offices, and records beingness misfiled in the file room. 1 hospital in the GAO study on automated medical records reported that information technology could not locate medical records 30 percentage of the time (GAO, 1991). Even when records are readily bachelor, the amount of time required to retrieve necessary information from a record tin frustrate users (Fries, 1974; Zimmerman, 1978; Pories, 1990).

For researchers, access to paper records can be problematic and is more often than not resource intensive (Davies, 1990). Identifying records that contain needed data, retrieving needed records, reviewing records, collecting data, and entering information into information sets for analysis are time-consuming, expensive tasks. Yet access to existing computer-based records can too bear witness hard for researchers because documentation on how to apply systems may be lacking. Further, information aggregation can be hampered by lack of compatibility amid systems.

Problems with Linkages and Integration

I of the major criticisms of the U.S. health care system is the discontinuity of care among providers (Rulin et al., 1988; Case and Jones, 1989). This aperture extends to patient records, whose lack of integration of inpatient and outpatient data is a significant deficiency. Paper patient records offer picayune hope of improving the coordination of health care services within or among provider institutions. Moreover, the inadequacy of patient tape interfaces with other clinical data, administrative information, or medical knowledge impedes optimal use of record information in providing patient care. Several health care systems and institutions have developed records that overcome many of the problems associated with traditional newspaper records, but fifty-fifty these improved records suffer from their lack of piece of cake transferability to other health care provider systems or institutions.

Outpatient Records

Attention is oft focused on patient records in hospitals rather than in outpatient settings. (An inpatient record is used past many different individuals during an episode of affliction, so its weaknesses tin can announced quite pronounced.) Yet outpatient records are greater in number, are scattered amongst private physician offices, and may exhibit even greater variance in quality than inpatient records. There are no established standards or review organizations for outpatient records as there are for inpatient records. As a outcome, outpatient records oft serve equally files for ''correspondence and reports rather than as a well organized chronology of health care" (Pories, 1990:49).

Ambulatory intendance records frequently contain poorly organized information, lack documentation of cardinal aspects of care, and exhibit inaccurate diagnostic coding (IOM, 1990c). Wellness care researchers and clinicians who conduct retrospective studies using such records are probable to identify at to the lowest degree 4 weaknesses: lack of standardization in content and format, inaccessibility (except in some hospitals or large health plans), incompleteness, and inaccuracies (Davies, 1990).

Information Management Challenges

An Information-Intensive Industry

Providing high-quality wellness care services is an information-dependent process. Indeed, the practice of medicine has been described as being "dominated" by how well information is candy or reprocessed, retrieved, and communicated (Barnett, 1990). An estimated 35 to 39 percentage of total infirmary operating costs have been associated with patient and professional communication activities (Richart, 1970). Physicians spend an estimated 38 percent (Mamlin and Baker, 1973) and nurses an estimated 50 percent (Korpman and Lincoln, 1988) of their time writing upward patient charts.

Data-processing activities associated with providing health services to patients are extremely varied. Clinicians obtain and record data about patients, consult with colleagues, read scientific literature, select diagnostic procedures, translate results of laboratory studies, devise strategies for patient care, instruct centrolineal health professionals, discuss care plans with patients and families, and document the progress of patients. In improver, wellness care practitioners must dribble knowledge, translate data, employ noesis, and manage the complexities of medical decision making (Haynes et al., 1989; Greenes and Shortliffe, 1990). Thus, health intendance professionals routinely need access to appropriate compilations of thorough, up-to-date cognition and advice to make prompt, informed decisions regarding patient intendance (Haynes et al., 1989; Saba et al., 1989; Greenes and Shortliffe, 1990). Furthermore, a wide range of information-processing tasks supports patient care, including performing laboratory tests, processing medical imaging data, capturing patient demographic information, filling prescription orders, monitoring quality and appropriateness of services provided, and billing (Martin, 1990).

An Information Explosion

For the past several years, wellness care practitioners have faced an explosion in medical knowledge. For instance, MEDLINE^ix now indexes approximately 360,000 new articles each year from those published in the biomedical literature (National Institutes of Health, 1989). Scientific and technological advances that accept contributed to improving the health of the public accept likewise resulted in more complexity in medical practice; clinicians must rails ever more numerous diagnoses, procedures, diagnostic tests, clinical processes, devices, and drugs.

The increase in bachelor technologies places an additional burden on physicians: they must read and synthesize the literature and try to decide whether and how new technologies should exist applied (Brook, 1989). Oft, a gap occurs between the data physicians demand and the data bachelor to them at the time of providing patient intendance. Co-ordinate to Covell and colleagues (1985), an estimated 70 percent of physician data needs are unmet during the patient visit.

In addition to more knowledge, there are more than data for wellness care professionals to manage. The volume and complexity of data per patient accept increased owing to a greater number of patient encounters (as patients live longer and experience chronic disease), higher patient acuity of illness (both in and out of hospitals), more than kinds of clinical information elements arising from new diagnostic technologies, and developments in the commitment system that result in many patients receiving care at multiple sites. Concomitant with increases in information, withal, have been efforts to reduce unit costs of wellness care provider institutions, which create pressures on health care professionals to be more than productive and to see more patients. This paradoxically reduces the time and free energy available for the functions associated with management and communication of information. Health intendance professionals are thus placed in a frustrating, difficult, and perhaps untenable position.

Increasing Demand for Data

Even equally patient intendance information become more voluminous and circuitous, the demand by multiple users for access to patient care information is increasing (Barnett, 1990). Information must be shared amidst the multiplicity of health intendance professionals who establish the "health care team." These professionals represent the physician specialties, besides as nurses, dentists, therapists, pharmacists, technicians, social workers, and other health care providers. Patients may as well require access to records; some providers abet greater patient input into the process of care through patient identification of preferences among treatments, patient contributions to the tape (particularly history and functional condition; Davies and Ware, 1988; Donnelly, 1988; Tarlov et al., 1989), patient reading and validation of record data, and patient command and send of pertinent parts of the record (Tufo et al., 1977; Bronson et al., 1978).

Administrators and managers of wellness care institutions require information to manage the quality of care provided and to allocate resources (e.k., labor, supplies, equipment, and facilities) according to the institution's patient instance mix. Managers of provider institutions seek to link financial and patient intendance information to develop meaningful budgets, measure productivity and costs, and evaluate market position. Long-term institutional planning for personnel recruitment, equipment acquisition, and facilities development depends on anticipated trends in patient population needs.

Quality assurance activities constitute another information need. Such activities are a requirement for accreditation of hospitals by the Articulation Commission on Accreditation of Healthcare Organizations (JCAHO); in addition, third-political party payers deport out various quality monitoring and evaluation efforts. The best known is probably the Medicare peer review organization programme administered by the Health Intendance Financing Administration (IOM, 1990c). Public and private third-party payers, medical professional societies, and researchers take been exploring exercise guidelines and outcomes management every bit tools for improving care (IOM, 1990a,b). The adventure direction programs established by many health care institutions in response to the recent history of medical malpractice litigation add together some other level of information use (IOM, 1990c).

Patient intendance information to adjudicate claims for reimbursement made to third-political party payers is an additional area of data needs. Equally expenditures related to health care have risen¹⁰ and as tertiary-political party payers have sought to contain costs, payers have also increased their demands for data. Patient data now are used for coverage decisions (e.g., preadmission review) likewise as for payment. Toll-containment approaches such as utilization management rely on individual patient information for making short-term decisions; they also rely on aggregated data to brand judgments about the effectiveness of medical services in the long-term (IOM, 1989). A recently developed hybrid of quality balls and cost containment—"value purchasing"—refers to the try past purchasers, providers, and consumers to promote "the idea of value or quality within the context of toll" (IOM, 1990c:36). Value purchasing requires admission to information on both costs and outcomes of care.

The public health arena is also seeking more and better data. The 1988 IOM report on the future of public health recommended that a uniform national data set be established to permit valid comparison of local, state, and national wellness data to facilitate progress toward achieving national health objectives (IOM, 1988). More than recently, the U.South. Public Wellness Service identified public wellness surveillance equally a principal means of supporting the national affliction prevention objectives for the year 2000 (U.S. Public Wellness Service, 1990). Data are needed to understand the health status of the U.South. population and to develop, administer, and evaluate public health programs aimed at controlling and preventing adverse health events. The Public Health Service report specifically mentions data on (1) bloodshed, morbidity, and disability from acute and chronic conditions; (2) injuries; (3) personal, environmental, and occupational run a risk factors associated with illness and premature decease; (4) preventive and handling services; and (5) costs.

The issues of quality, toll, effectiveness, and ceremoniousness largely frame the questions that today's clinical and health services researchers pursue. Efficacy and condom are no longer sufficient criteria for assessing a engineering science whose purchasers also desire to know (1) whether it is effective and safe outside the controlled environment of clinical trials, (2) whether information technology is toll-effective, and (3) whether it produces desired outcomes. "[50]ongitudinal observations of natural variations in use and outcomes of economically and clinically important medical technologies in unlike practice situations" are sought to back up utilization management (IOM, 1989:158).¹¹

Tardily in 1989, the Bus Budget Reconciliation Act (P.L. 101–239) established the Agency for Health Intendance Policy and Inquiry (AHCPR) to heighten "the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad base of scientific research and through the promotion of improvements in clinical practice and in the organization, financing and delivery of health care services" (U.S. Congress, 1989). In addition to its mandate to "deport and support research, demonstration projects, evaluations, training, and the dissemination of information, on health care services and on systems for the delivery of such systems," AHCPR is specifically directed to support the improvement and supplementation of existing databases and the blueprint and development of new databases for use in outcomes and effectiveness research.

More than recently, several IOM studies accept endorsed efforts to back up, expand, and improve research and the knowledge base of operations on efficacy, effectiveness, and outcomes of care (IOM, 1990b,c). Such efforts are part of a systematic effort to develop clinical practice guidelines and standards of care. All of these activities underscore the vastly increased need for patient information that has emerged during the 1980s.

Maintaining Confidentiality

In contrast to these trends—an increased supply of and demand for patient data—is the absolute necessity to protect patient privacy. ¹² The ancient principle of confidentiality—the obligation of health care professionals to avert violating a patient's right to privacy—is affirmed past the American Medical Association (AMA) Council on Ethical and Judicial Affairs (1989).¹³ Thus, a meaning claiming in creating future patient tape systems is to attain an appropriate remainder betwixt confidentiality and access by users with a need to know.¹⁴

Data Management Opportunities

Some health care provider institutions are well on their style toward developing new electronic approaches to patient records. This progress has been possible because of advances in computer technology and successful research on the application of such engineering to medicine. These advances include, just are not limited to, hand-held computers; picture archiving and communications systems that permit electronic storage, manual, and brandish of medical images; disk drives that offer mean fourth dimension between failures of sixty,000 or more hours; and high-speed telecommunications networks that can carry 1.7 billion characters per second over a 100-kilometer link. New technologies and applications such equally these tin potentially improve the quality of patient care, advance the scientific basis of medicine, moderate the costs of health care services, and heighten the didactics of health care professionals.

Computer-based patient records, as defined by the committee, could positively bear upon the quality of patient intendance in at to the lowest degree four ways. Showtime, they offer a means of improving both the quality of and access to patient care information. 2d, they permit providers to integrate information about patients over time and between settings of care. Third, they make medical knowledge more accessible for use past practitioners when needed. Quaternary, they provide decision support to practitioners.

Research efforts could too benefit from computer-based patient record keeping in ii cardinal ways. First, improved data and access to those data would be bachelor to researchers. Second, enquiry findings could exist communicated to practitioners through calculator-based patient record systems

Estimator-based patient records could help efforts to moderate the costs of health care in three means. First, improved information could reduce redundant tests and services that are performed in response to the unavailability of test results. Second, administrative costs could be reduced by electronic submission of claims and the ability to generate routine reports automatically. Third, the productivity of practitioners could be enhanced by (1) reducing the time needed to find missing records or to wait for records already in utilise; (2) reducing, if not eliminating, the demand for redundant data entry; and (iii) reducing the time needed to enter or review information in records that take been streamlined to eliminate unnecessary information.

Health care professionals not but encourage self-directed learning among their students (Gastel and Rogers, 1989) but are viewed as having a responsibility for continuing lifelong education (AAMC, 1984). Students thus crave skills in organizing information and solving problems. Computer-based patient records can support information management and contained learning by health care students and professionals in both patient care and clinical research settings. Tools for such learning include clinical decision support systems, bibliographic and noesis links (including links to clinical practise guidelines), and statistical software.

Beyond Applied science

Meeting the claiming of managing wellness care information depends on more than technological advances. The usefulness of any technology depends on how well it and its progeny are applied. In improver to applied science, a written report of the comeback of patient records must accost how the apply of those records might be improved, a question that raises potentially sensitive problems.¹⁵ "Improving records" and "improving clinical reasoning" are topics inevitably continued to one another because ideally the record reflects the clinical reasoning process. If better tape systems are to be created in the hereafter, the user must be recognized as role of the organisation, and the trouble solving activities of practitioners must be examined.

In improver to technological and behavioral opportunities for improving patient records, certain strategic problems must exist addressed. Other data-intensive industries (e.yard., banking) accept successfully implemented widespread computer-based information direction technologies. Understanding the factors that have slowed the development and diffusion of such technologies in health care is a first step toward achieving more than rapid advances in the futurity.

Why Now?

Many attempts have been fabricated over the years to accelerate clinical computing, to reform the patient record, and to encourage wellness intendance professionals to maintain the record more conscientiously (e.1000., by entering necessary clinical data). Why should or how could renewed efforts to establish the routine use of new figurer-based record systems succeed now when previous attempts accept failed? Why might this report have a meaning impact?

The commission believes that five weather of the environment in which its strategic plan might be implemented increment the likelihood of achieving widespread use of reckoner-based patient records. First, electric current demands for patient information throughout the health care sector volition non diminish; indeed, they will probably increase. Second, technologies essential to computer-based patient records are becoming more powerful and less expensive Third, patients and practitioners gradually are condign accustomed to the use of computers in nearly all facets of everyday life. Fourth, an crumbling and mobile population results in more than data to exist managed and demands for improved transferability or portability of that information. Finally, the committee believes that those components of needed reform in health care that crave evaluation, consolidation of information, and improved communication will not easily be accomplished without reforms in the scope, use, and automation of the patient record.

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1: The committee uses the term practitioners to refer to all health care professionals who provide clinical services to patients. These professionals include, but are not limited to, physicians, nurses, dentists, and therapists.
2: The IOM commission was originally named the Commission on Improving the Medical Record in Response to Increasing Functional Requirements and Technological Advances. The committee's commencement action was to change "medical" to "patient" in its proper noun, reflecting its consensus that the medical component of the tape does not constitute the total tape. Thus, this report generally will refer to what are unremarkably chosen medical records as "patient records.'' In that location are several instances, however, in which the committee continues to refer to medical records rather than patient records. For example, the commission's official charge relates to medical records, and the committee has not undertaken to rename "medical record professionals."
3: Shortliffe and colleagues define a clinical decision back up arrangement as "whatever estimator system designed to assistance health professionals make clinical decisions" (Shortliffe et al., 199$1$2$369). They place three types of decision support functions: information management, focusing of attention, and patient-specific consultation. Throughout this report, clinical decision back up systems refer to clinical consultation systems that utilise population statistics or encode expert knowledge to assist practitioners in diagnosis or in formulating treatment plans (Shortliffe et al., 1990).
4: The committee's distinction between principal and secondary patient records parallels, just is not identical to, the approach used by Westin (1976). Westin identified 3 "zones" through which information flows: (1) direct patient care, (ii) supporting activities, and (3) social uses of health information. This report does non address social uses of patient intendance data that lie outside health care (e.one thousand., police enforcement) and combines supporting activities and health care social uses of patient data into one zone.
5: Wellness care professionals might maintain a carve up patient record to protect sensitive information (eastward.g., psychiatric history) or to support a research involvement (i.e., separate records containing detailed data for a research project).
6: Pharmacies capture data pertinent to patient care but do not maintain total patient records. Information on the medications prescribed and the specialties of the physicians writing the prescriptions can provide enough data to determine a patient's medical problems, notwithstanding, and pharmacy records may thus raise confidentiality issues similar to those associated with patient records. Considering the committee focused more closely on traditional patient intendance records, this study does not accost issues related to pharmacy records.
7: Chapter 3 highlights some of the health care provider institutions at the leading border of patient record technologies.
viii: Although flexibility in recording data may be viewed as a force by the individual recording the information, lack of standard vocabulary and coding can pose problems for subsequent users—including practitioners, administrators, researchers, and third-party payers.
9: MEDLINE is an on-line bibliographic database of medical information. It covers 25 years and includes citations to more than half-dozen meg articles from approximately 3,500 journals. MEDLINE is part of the National Library of Medicine Medical Literature Assay and Retrieval System (MEDLARS), which includes specialized databases in wellness administration, toxicology, cancer, medical ethics, and population studies (National Institutes of Health, 1989).
10: Health care expenditures accounted for 7.3 percentage of the nation's gross national production (GNP) in 1970 (Levit et al., 1990). In 1989, wellness intendance spending amounted to 11.6 percent of GNP (U.S. Department of Health and Human Services, 1990).
11: 1 proficient has suggested that "[w]lid is needed is a new kind of trial, one that combines randomized prescription of approved drugs and easily-off follow-up with recording of medical outcomes and decision of costs from routinely generated computerized patient records" (Paterson, 1988:112).
12: Privacy is the right of individuals to be left alone and to be protected against physical or psychological invasion or the misuse of their property. It includes "freedom from intrusion or observation into one's individual affairs; the right to maintain control over certain personal information; and the freedom to act without outside interference" (Peck, 1984).
13: "And whatever I shall see or hear in the form of my profession, as well equally exterior of my profession in my intercourse with men, if it be what should not exist publicized away, I will never divulge, belongings such things to be holy secrets" (Hippocratic Adjuration, equally quoted in Modest, 1989).

According to the AMA, "[t]he information disclosed to a physician during the course of the human relationship betwixt medico and patient is confidential to the greatest extent possible. The patient should feel free to make a full disclosure of information to the doctor in order that the dr. may most effectively provide needed services. The patient should exist able to make this disclosure with the cognition that the physician will respect the confidential nature of the communication" (AMA Council on Ethical and Judicial Affairs, 1989:21).
14: Concerns most the privacy of data are not limited to health intendance data. The 1977 report, Personal Privacy in an Information Society , cited consumer credit, depository, insurance, employment, and teaching information every bit all needing protection (Privacy Protection Study Commission, 1977).
15: Examination of the role of patient records in the clinical process, as manifested in the fence surrounding the problem-oriented record, has been under mode for more than than 20 years (Weed, 1968; Goldfinger, 1972; Margolis, 1979).