National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R1
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R2
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R3
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R4
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R5
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R6
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R7
Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R8
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R9
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R10
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R11
Suggested Citation:"Front Matter." Institute of Medicine. 1991. Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: The National Academies Press. doi: 10.17226/18459.
×
Page R12

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Kti-tKh'NCE CO' FOR WVM \ THE COMPUTER-BASED PATIENT RECORD An Essential Technology for Health Care Committee on Improving the Patient Record Division of Health Care Services INSTITUTE OF MEDICINE Richard S. Dick and Elaine B. Steen, Editors PROPERTY OF NRC LIBRARY OCT25 '91 NATIONAL ACADEMY PRESS . , hn,Mi Washington, D.c. 1991 National Technical Information Service, Springfield, Va, 22161 Order No. .

NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy mat- ters pertaining to the health of the publie. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported by the American Medical Record Association, Baxter Healthcare Corporation, Booz-Allen and Hamilton, E. I. Dupont de Nemours and Company, Gerber Alley and Company, the John A. Hartford Foundation, Hewlett-Packard Company, IBM Corporation, Kaiser Foundation Hospitals, and Science Applications International Corporation. In addition, the Health Care Financing Administration (Contract No. 500-90-0041), the Department of Veterans Affairs (Contract No. 101-C90014), and the Health Resources and Services Adminis- tration provided financial support. Finally, the Agency for Health Care Policy and Research (Contract No. 282-90-0018) provided funds for a workshop that contributed to the delibera- tions of the study committee; the former National Center for Health Services Research pro- vided funds for planning efforts before the study began (Grant No. 5909 HS055 2602). Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.) Committee on Improving the Patient Record. The computer-based patient record : an essential technology for health care / Committee on Improving the Patient Record, Division of the Health Care Services, Institute of Medicine ; Richard S. Dick and Elaine B. Steen, editors, p. cm. Includes bibliographical references and index. ISBN 0-309-04495-2 1. Medical records—Data processing. I. Dick, Richard S. II. Steen, Elaine B. HI. Title. [DNLM: 1. Computers. 2. Medical Informatics. 3. Medical Records. WX 173 I59c] R864.I55 1991 651.5'04261'0285—dc20 DNLM/DLC 91-23584 for Library of Congress CIP Copyright © 1991 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purposes of official use by the U.S. government. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logo- type by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

COMMITTEE ON IMPROVING THE PATIENT RECORD IN RESPONSE TO INCREASING FUNCTIONAL REQUIREMENTS AND TECHNOLOGICAL ADVANCES DON E. DETMER (Chair),* Professor of Surgery and Business Administra- tion and Vice President for Health Sciences, University of Virginia, Charlottesville MARION J. BALL, Associate Vice President for Information Resources, University of Maryland, Baltimore G. OCTO BARNETT,* Professor of Medicine, Harvard Medical School, and Director, Laboratory of Computer Science, Massachusetts General Hospital, Boston DONALD M. BERWICK, Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts MORRIS F. COLLEN,* Director Emeritus and Consultant, Division of Research, Kaiser Permanente Medical Care Program, Oakland, California NICHOLAS E. DA VIES,t Practitioner of Internal Medicine, Atlanta, Georgia RUTH E. GARRY, Senior Manager, Group Benefits Services Division, CNA Insurance Companies, Chicago, Illinois THOMAS Q. MORRIS, Professor of Clinical Medicine, College of Physicians and Surgeons of Columbia University, and Past President, Columbia Presbyterian Medical Center, New York, New York JOHN A. NORRIS, Corporate Executive Vice President, Hill and Knowlton, Inc., Waltham, Massachusetts, and Lecturer in Health Law, Harvard School of Public Health, Boston, Massachusetts EDWARD H. SHORTLIFFE,* Professor of Medicine and Computer Science; Head, Division of General Internal Medicine; and Director, Medical Information Sciences Training Program, Stanford University School of Medicine, Palo Alto, California LIAISON MEMBERS HENRY KRAKAUER, Director, Office of Program Assessment and Information, Health Standards and Quality Bureau, Health Care Financing Administration, Baltimore, Maryland DONALD A. B. LINDBERG,* Director, National Library of Medicine, National Institutes of Health, Bethesda, Maryland *Member, Institute of Medicine, t Deceased, April 1991.

Study Staff RICHARD S. DICK, Study Director ELAINE B. STEEN, Staff Officer EVANSON H. JOSEPH, Project Secretary KARL D. YORDY, Director, Division of Health Care Services KATHLEEN N. LOHR, Deputy Director, Division of Health Care Services IV

Preface Health care professionals and policymakers seeking to ensure greater value in health care services face many boundary conditions that are fixed and a host of problems that are not. Today, the opportunity to affect one of those boundary conditions—the information management capabilities in health care—is within our grasp. This report advocates the prompt development and implementation of computer-based patient records (CPRs). Put simply, this Institute of Medicine committee believes that CPRs and CPR systems have a unique potential to improve the care of both individual patients and populations and, concurrently, to reduce waste through continuous quality improvement. We are not suggesting a simple automation of the current patient record. Rather, we envision the next generation of CPRs and CPR systems as essen- tial to the full maturation of the scientific basis of health care. The report outlines the basic components of future CPRs and a strategic plan for achieving widespread CPR implementation. Further, it identifies the key organiza- tions that will need to play major roles if the plan is to succeed. The vision of the patient record of the future that emerged from the committee's deliberations seems uniquely appropriate for a nation that val- ues pluralism and privacy and has a mobile population with growing levels of chronic illness. CPRs are a key infrastructural requirement to support the information management needs of physicians, other health profession- als, and a variety of other legitimate users of aggregated patient informa- tion. It is this vision, as much as any other message, that the committee hopes will engage the reader. We believe that if enough individuals be- come embued with this sense of the possible, the reality will emerge.

vi THE COMPUTER-BASED PATIENT RECORD Our report is intended for a very broad audience. We see it as especially pertinent for physicians and other health care practitioners; health care managers; medical record professionals; health services researchers; medical informatics researchers; computer vendors; third-party payers; the legal community; federal, state, and local health care agencies; state legislators; members of the federal legislative and executive branches of government; and, finally, interested citizens. All these parties, we believe, have much to gain from the success of CPRs and CPR systems. Happily, this report complements and is complemented by several other recent activities that convinced us, as we proceeded with our work, that the time was ripe for a major CPR initiative. The Office of Science and Data Development of the Agency for Health Care Policy and Research (AHCPR) is leading efforts to improve the quality and quantity of data available for health services research—particularly effectiveness, appropriateness, and out- comes research. In addition, the AHCPR Forum on Quality and Effective- ness in Health Care, the American Medical Association, and other profes- sional organizations are playing a major national role in the development of clinical practice guidelines. The CPR will be a boon to both these endeavors. The activities of several other groups also lend support to the move toward widespread implementation of computer-based records. The Gen- eral Accounting Office recently released a forward-looking report on the potential benefits of patient record automation. Several Institute of Medi- cine reports published over the last two years cite the need for improved patient data collection to support quality assurance, utilization management, and effectiveness research. The National Science Foundation recently is- sued a report on the benefits of a national system for very high speed data communication, including health data. Finally, the National Research Council's recently released report on safe computing in the information age outlines problems and opportunities in computer security. Given this apparent climate of opportunity for CPR development and implementation, the committee came to the end of its work eager to dis- seminate its message regarding the feasibility and potential of CPRs and CPR systems. The natural ebullience common to the conclusion of a study was tempered, however, by the untimely death of committee member Ni- cholas E. Davies. Dr. Davies saw more clearly than many of us what needed to be done to implement the vision of fully developed patient records and had committed his considerable personal energies to achieving our col- lective goals for CPRs and CPR systems. For this reason we feel it appro- priate to dedicate this report to him and to his belief in our vision. If this project is to succeed, we must soon see organizational efforts that adopt and implement, or refine and implement, our recommendations. Suc- cess will require cooperation and coordination, and perhaps some sacrifice and compromise as well, but we are fully convinced that the outcomes will

PREFACE vii be well worth such an effort. What we believe will emerge will be a more caring, more scientific, and, no less important, more cost-effective health care system. We hope that this report will be a catalyst to encourage you to join with us to address the opportunity at hand. Finally, on a personal note, the enthusiasm, involvement, and support of the many individuals and institutions acknowledged elsewhere in this report were deeply appreciated. Don E. Detmer, M.D. Chair

Acknowledgments The committee would like to express its appreciation for the contribu- tions of many individuals and organizations to this project. In addition to the subcommittee members listed in Appendix A, more than 200 individuals representing organizations throughout the health care sector attended sub- committee meetings or submitted written information, providing the com- mittee with a broad base of information from which to draw. Several subcommittee members led work groups or prepared papers and presenta- tions. Subcommittee chairs and assistant chairs in particular devoted sig- nificant amounts of time preparing for their meetings and writing reports of subcommittee findings for use by the full study committee. Several individuals prepared background papers that were most helpful to the study committee and staff. In addition to Adele Waller (whose paper appears in this volume), the committee acknowledges the contributions of Paul Tang, Donald Lindberg and Betsy Humphreys, Margret Amatayakul and Mary Joan Wogan, John Silva, and Orley Lindgren and Don Harper Mills. The committee also expresses its gratitude to the participants of a workshop on overcoming barriers to patient record development who pro- vided the committee with a sounding board for its ideas about an organiza- tional framework to accelerate such development. This study would not have been possible without financial support from many entities. Within the private sector, we acknowledge generous support from the American Medical Record Association, Baxter Healthcare Corpo- ration, Booz-Allen and Hamilton, E. I. Dupont de Nemours and Company, Gerber Alley and Company, the John A. Hartford Foundation, Hewlett- Packard Company, IBM Corporation, Kaiser Foundation Hospitals, and Sci- IX

X ACKNOWLEDGMENTS ence Applications International Corporation. Within the public sector, the Department of Veterans Affairs, the Health Care Financing Administration, and the Health Resources and Services Administration provided important funding for the study. The Agency for Health Care Policy and Research (AHCPR) sponsored a workshop on overcoming barriers to patient record development that provided valuable information for the committee's delib- erations. Preliminary staff work on the study was supported in part by the Institute of Medicine Council on Health Care Technology, which received financial support from AHCPR's predecessor, the National Center for Health Services Research and Health Care Technology Assessment. We are indebted to several Institute of Medicine staff members. Enriqueta Bond and Richard Rettig oversaw the initiation of the project. Maria Elena Lara and Ethan Halm provided staff support, and Clifford Goodman (now with the Swedish Council on Technology Assessment in Health Care) pro- vided guidance in the early stages of the study. Karl Yordy, and particu- larly Kathleen Lohr, helped steer the study through its later phases. Elaine Steen and Richard Dick provided staff support throughout the study and were responsible for preparing this report on behalf of the committee. All studies rely on the efforts of administrative and financial staff for day-to-day operations. The committee appreciates the contributions of Holly Dawkins, Suzanna Gilbert, Evanson Joseph, Theresa Nally, Delores Sutton, and H. Donald Tiller in project administration and Cynthia Abel, Lisa Chimento, and Nina Spruill in financial administration. Finally, we thank Leah Mazade for her editorial comments on this report.

Contents SUMMARY 1 User Needs and System Requirements, 2 Computer-Based Patient Record Technologies, 4 Nontechnological Barriers, 4 Recommendations, 6 1 INTRODUCTION 8 The Study, 9 Report Organization, 12 The Patient Record, 12 Information Management Challenges, 19 Information Management Opportunities, 24 Beyond Technology, 25 Why Now? 25 2 THE COMPUTER-BASED PATIENT RECORD: MEETING HEALTH CARE NEEDS 30 Defining Health Care Needs, 30 Translating Customer Needs into System Requirements, 35 The Future Patient Record, 50 3 COMPUTER-BASED PATIENT RECORD TECHNOLOGIES 56 Technological Building Blocks for CPR Systems, 56 Experience with CPR Systems, 67 An Overview of CPR Systems, 69 XI

XII CONTENTS Clinician Interaction and Resistance, 81 Technological Barriers, 82 Summary, 87 Appendix: The Computer-based Patient Record System Vendor Survey, 91 4 THE ROAD TO CPR IMPLEMENTATION 94 Development and Diffusion Factors, 94 Elements of an Implementation Strategy, 107 Summary, 125 Appendix: Maternal and Child Health Care and Computer-based Patient Records, 129 5 IMPROVING PATIENT RECORDS: CONCLUSIONS AND RECOMMENDATIONS 132 Conclusions, 134 Recommendations, 136 Summary, 151 APPENDIXES A SUBCOMMITTEES 153 B LEGAL ASPECTS OF COMPUTER-BASED PATIENT RECORDS AND RECORD SYSTEMS 156 Adele A. Waller INDEX 181

THE COMPUTER-BASED PATIENT RECORD

Next: SUMMARY »
Computer-Based Patient Record: An Essential Technology for Health Care Get This Book
×
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF
  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!