Computer-Based Patient Record An Essential Technology for Health Care (1991) / Chapter Skim
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THE COMPUTER-BASED PATIENT RECORD: MEETING HEALTH CARE NEEDS
THE COMPUTER-BASED PATIENT RECORD: MEETING HEALTH CARE NEEDS
Pages 30-55
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From page 30... ...
For example, in the patient record of the future, the committee seeks the ability to access quickly a list of current problems, a trail of clinical logic, the patient's health status, and the most recent information about various treatment options for the patient's condition. Easy access to and sound organization of data elements can be provided by automation of patient records, but the availability of the data elements depends on whether practitioners collect and record such data in the first place.
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From page 31... ...
Patient record users provide, manage, review, or reimburse patient care services; conduct clinical or health services research; educate health care professionals or patients; develop or regulate health care technologies; accredit health care professionals or provider institutions; and make health care policy decisions. All of these kinds of users are "customers" of the patient record, and their needs should be met by patient record systems of the future.
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From page 32... ...
, patients, administrators, thirdparty payers, and researchers.2 Patient Record Uses Just as the range of patient record users includes more than physicians, nurses, and other health care professionals, patient record uses extend beyond direct patient care. Similar to a comprehensive list of users, a complete list of uses would be quite long.
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From page 33... ...
Psychiatric facilities Public health departments Substance abuse programs Management and Review of Care Medicare peer review organizations Quality assurance companies Risk management companies Utilization review and utilization management companies Reimbursement of Care Business health care coalitions Employers Insurers (federal, state, and private) Research Disease registries Health data organizations Health care technology developers and manufacturers (equipment and device firms, pharmaceutical firms, and computer hardware and software vendors for patient record systems)
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From page 34... ...
Patient Care Management Document case mix in institutions and practices Analyze severity of illness Formulate practice guidelines Manage risk Characterize the use of services Provide the basis for utilization review Perform quality assurance Patient Care Support Allocate resources Analyze trends and develop forecasts Assess workload Communicate between departments Billing and Reimbursement Document services for payments Bill for services Submit insurance claims Adjudicate insurance claims Determine disabilities (e.g., workmen's compensation) Manage costs Report costs Perform actuarial analysis the environment in which patient care is provided.
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From page 35... ...
BOX 2-2B SECONDARY USES OF PATIENT RECORDS Education Assess technology Document health care profes- Study patient outcomes sional experience Study effectiveness and costPrepare conferences and effectiveness of patient presentations care Teach health care professions Identify populations at risk students Develop registries and databases Assess the cost-effectiveness of Regulation record systems Serve as evidence in litigation Foster postmarketing surveillance Policy Assess compliance with Allocate resources standards of care Conduct strategic planning Accredit professionals and Monitor public health hospitals Compare health care organizations Industry Conduct research and developResearch ment Develop new products Plan marketing strategy Conduct clinical research
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From page 36... ...
Trend reports and graphics Control and Access Easy access for patients and their advocates Safeguards against violation of confidentiality Training and Implementation Minimal training required for system use Graduated implementation possible In compiling the list of user requirements, the committee noted two special considerations. First, user needs can conflict with each other -- not just among groups (e.g., patients and practitioners need confidentiality, but claims payers seek access to detailed clinical information)
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From page 37... ...
" but also, "What would people want if they knew what could be done for them? " Patient Record Functions The traditional function of patient records has been to store information relevant to the care of a patient for subsequent retrieval.
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From page 38... ...
In addition, record systems should allow users to "flip through" or easily scan records; a table of contents or index would be helpful for this purpose. BOX 2-4 DIFFERENT USERS NEED DIFFERENT LEVELS AND KINDS OF DATA A patient record database contains many data elements, and each user community has a unique, definable "view" of the database that brings together the elements needed by that community.
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From page 39... ...
4This statement assumes that record users will receive adequate training in how to use patient records and the other functions provided by patient record systems through formal education (i.e., professional schools and continuing education)
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From page 40... ...
. Data accuracy also has implications for the security and reliability of CPR systems insofar as the systems must ensure that data are not lost or unknowingly corrupted.5 The completeness of patient records for subsequent users depends in part on agreement among users about uniform core data elements.
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From page 41... ...
Maintaining the quality of patient data also requires that the data have meaning for users. Effective retrieval and use of information from patient records depend on consistency in naming or describing the same findings, clinical problems, procedures, drugs, and other data within a single patient record, across many patient records in a single record system, or in other systems that contain data relevant to the understanding and treatment of patient problems.
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From page 42... ...
Consistent description of clinical content becomes more important with the aggregation of data from many patient records -- as in outcomes research, for example. Standardized data dictionaries, coding schemes, and uniform data sets permit more complete, reliable analyses of care and disease patterns involving multiple sites.7 SECURITY CPR systems have two security requirements.
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From page 43... ...
. Data integrity in future patient records might be enhanced by including a data validity field that would flag data that might not be correct.
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From page 44... ...
Linkages among the various clinical records pertaining to a single patient are also important to users, who often want a longitudinal patient record -- records from different times, providers, and sites of care that are linked to form a lifelong view of a patient's health care experiences. Linkages are also needed to transfer patient data from one care setting to another (e.g., from physician office to hospital)
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From page 45... ...
Health care professionals perform many routine administrative tasks in the course of providing services, and they seek ways to reduce this administrative burden so that they can devote more time to direct patient care, research, and education. Patient record systems should provide the capacity to generate routine documents based on record data automatically, to submit insurance claims electronically, and to report adverse reactions or occurrences of tracked diseases automatically.
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From page 46... ...
(Weed, 1968; Margolis, 1979) .12 Studies investigating the use of the problem-oriented format to record the patient care process report three advantages over non-problem-oriented 12The problem-oriented medical record categorizes clinical information relevant to the medical care of the patient into four functional groups.
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From page 47... ...
. The committee unanimously believes that patient records should guide and reflect clinical problem solving and that the mere translation of current record formats, data, and habits from paper to computer-based systems will not alone produce the range of improvements in care potentially achievable in a truly reformed patient record system.
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From page 48... ...
. CPR systems can support practitioners in the patient care setting by providing easy access to knowledge and bibliographic databases.
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From page 49... ...
sorting information in one record or information aggregated across multiple records; (3) aggregating data across patients by hospital, patient care unit, and department; and (4)
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From page 50... ...
First, future patient records must support patient care and improve its quality. Second, they must enhance the productivity of health care professionals and reduce the administrative and labor costs associated with health care delivery and financing.
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From page 51... ...
Physician offices will be able to communicate with local hospitals and with national bibliographic resources such as MEDLINE. In the larger health care environment, computer-based information management systems will be able to communicate with information systems of provider institutions, third-party payers, and other health care entities.
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From page 52... ...
Individual practitioners Clinical services and departments laboratory nursing pharmacy radiology Administrative, management, and support services and departments admitting finance risk management External Sources or Recipients of Patient Data Other provider institutions hospitals nursing homes physicians' offices Other patient care settings inpatient outpatient (including home health) Secondary patient records educational institutions for the health professions quality assurance and accreditation agencies registries and databases researchers state and local public health agencies third-party payers FIGURE 2.1 Computer-based patient records as the core of health care information systems.
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From page 53... ...
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From page 54... ...
can be brought to health care professionals at the time and site of patient care. It also includes providing opportunities for reducing administrative costs associated with health care financing and collecting administrative data for internal and external review.
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From page 55... ...
1989. Advances in health status assessment: Conference proceedings.
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