Computer-Based Patient Record An Essential Technology for Health Care (1991) / Chapter Skim
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COMPUTER-BASED PATIENT RECORD TECHNOLOGIES
COMPUTER-BASED PATIENT RECORD TECHNOLOGIES
Pages 56-93
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From page 56... ...
That is, no operational clinical information system in 1990 can manage the entire patient care record with all its inherent complexities. A few existing clinical information systems are beginning to approach the CPR system capabilities envisioned by the committee.
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From page 57... ...
This section describes the key attributes of these crucial technologies. Databases and Database Management Systems It is important to distinguish between the clinical data -- that is, the computerbased patient record, or CPR -- and the system that captures and processes those data -- that is, the CPR system.
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. If the patient's clinical data are physically distributed among several computers in a network, a comprehensive view of the record of a given patient can be achieved only by retrieving and assembling the pertinent data from each computer on the network where patient data reside.
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The CPR is so complex that no single database management system is capable of optimally storing and retrieving the full range of patient data (Hammond et al., 1990)
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may well become one of the more powerful tools ever devised for health care professionals and may ultimately come to be considered indispensable. Data Acquisition and Data Retrieval Data Acquisition Data acquisition for the CPR remains an exceptionally challenging topic within the field of medical informatics.3 Ideally, data in the CPR should be entered at its source (e.g., the site of patient care)
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From page 62... ...
Text Processing To establish a diagnosis, physicians and other health care professionals use patient information in a textual form -- for example, the patient history and the results of the physical examination. With a CPR system, professionals search for and retrieve such text from database systems using query languages, which in the past were often idiosyncratic to a particular system.
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From page 63... ...
Data-Exchange and Vocabulary Standards In today's health care environment, health care professionals, managers, policymakers, regulators, and educators need increasing amounts of accurate health care data in machine-readable form to support intelligent decision making. All such data must be collected, aggregated (when they come from diverse sources)
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From page 64... ...
on computerized systems that are dedicated to standards directly related to the transfer of clinical data, such as those found in the patient record. Among other topics, these ASTM standards committees have focused on naming conventions and have proposed data element names for clinical data found in the patient record.
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From page 65... ...
The patient information conveyed is complex and appears in all possible modalities, including text, images, voices and sounds, signals, and video. This broad array of information needs to be available in such diverse locations as the bedside, the hospital department, professional offices, emergency settings including mobile units, and the home.
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From page 66... ...
Members of the health care team who record patient data in the record are responsible for such entries, but in a hospital or clinic, physicians typically still have primary responsibility for ensuring the record's accuracy. As documentation of health care shifts from paper to computerbased records, practitioners will maintain their responsibility to document patient care, but the data will reside within CPR systems.
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The systems of most interest to this report are clinical information systems, also sometimes known as patient care management systems. Clinical information systems consist of components related to clinical or direct care of patients (Blum, 1986)
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. Other than in developmental projects, computerized medical records are abstracts of more complete records maintained in hard copy form." With the advent of less costly mini- and microcomputers, clinical information system development flourished during the 1970s and 1980s.
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AN OVERVIEW OF CPR SYSTEMS A distinguishing feature of the clinical information systems that can rightly be called computer-based patient record systems is their underlying database management system. Generally, for performance reasons, CPR systems have developed their own DBMS and have avoided the use of commercially available products.
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Physician Offices and Group Practice Settings The Medical Record For more than 20 years, the Duke University Medical Center8 has been developing a comprehensive medical information system known as The Medical Record (TMR)
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system, which became one of the first systems capable of producing a computer-based patient record.10 COSTAR is a medical information management and record system designed as a set of modules for which individual sites can choose the portions of the system they wish to install. COSTAR supports patient registration, scheduling of patient visits, storage and retrieval of clinical information, and billing and accounts receivable (Barnett, 1984)
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The COSTAR system is comprehensive enough to include all major categories of clinical data, including laboratory results and findings from diagnostic procedures. All data recorded in the patient record are associated with controlled vocabulary terms (and any selected modifiers)
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From page 73... ...
The system maintains a lifelong record and never deletes clinical data. Physicians and other members of the health care team enter these data directly using "windowing" terminals (a feature that permits users to look at different data or views of the same data on the terminal screen at the same time)
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From page 74... ...
Much of the input to HELP comes directly from medical professionals entering data at terminals, but wherever possible HELP utilizes automated input of the patient's clinical data. Although LDS has conducted experiments using an automated patient history, currently only minimal history and physical examination data are contained in the HELP record.
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From page 75... ...
Beth Israel and Brigham and Women's Hospital System The clinical information system at Beth Israel Hospital in Boston, Massachusetts, was developed by the Harvard Medical School's Center for Clinical Computing and has been in continuous use and evolution for more than a decade (Bleich and Slack, 1989) .14 The system at Brigham and Women's Hospital in Boston, also from the Clinical Computing Center, was modeled after Beth Israel's system and required approximately four years to develop.
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The VA's DHCP consists of software grouped into three categories: (1) 15At the direction of Congress the VA has installed commercially developed clinical information systems in a few selected VA medical centers to test the VA's DHCP against systems from the private sector.
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Department of Defense The Department of Defense (DoD) has contracted for the deployment of a clinical information system at its hundreds of care facilities around the world (General Accounting Office [GAO]
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In Exeter, 98 percent of the pharmacies, 70 percent of general practitioners, and all hospitals are able to read and use the credit card-sized patient Care Cards. 16Smart cards are electronic devices (usually encased in plastic)
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These and other experiments in Europe imply that Europeans have significant experience in developing clinical data standards, perhaps more than most other regions of the world. Further, they indicate the very real need for greater international cooperation in formulating future health care data standards.
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Such tools cannot be used by health care professionals, however, until clinical data are captured in machine-readable form. In short, the CPR must come first.
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Clinical data derived from operational CPR systems will contribute significantly to the body of medical knowledge used by future medical decision support systems. Indeed, it is highly probable that CPR systems may realize their full impact only when used in conjunction with medical decision support systems.
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. Experience demonstrates that providing a fee for data entry does have a positive impact.
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As vocabularies expand, both the costs and error rates generally become intolerable. Emerging voicerecognition technology is likely to ease the inputting of clinical data in future CPR systems, but the successful experiences discussed earlier with such systems as HELP, THERESA, and DIOGENE confirm the existence of currently available alternative approaches to capturing crucial clinical data (including text)
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From page 84... ...
The outermost zone contains the least sensitive information, which may or may not be confidential. The area between these two zones is the one containing sensitive information, probably related mainly to illnesses and health problems; it is likely to be the largest area in terms of volume of the CPR and the one most frequently associated with traditional medical confidentiality requirements.
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Many vendors and government agencies have independently developed their own internal clinical data dictionaries. These dictionaries differ in terms of the actual data elements included, naming conventions, definitions, and relationships among data elements.
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Other Public & Private Sector Parties / i \ Template Generation Process Third-Party^ System Payers and \ Vendors Insurers \ \ Use Data-Exchange Standards to Transfer Set of Clinical Data Defined in Template FIGURE 3-3 Concept of a composite clinical data dictionary. Abbreviations: ACR/ NEMA, American College of Radiologists/National Electrical Manufacturers Association; AHA, American Hospital Association; AMA, American Medical Association; AMIA, American Medical Informatics Association; AMRA, American Medical Record Association; ANA, American Nurses Association; ASTM, American Society for Testing Materials; DoD, Department of Defense; HCFA, Health Care Financing Administration; IEEE, Institute of Electronic and Electrical Engineers; ISO, International Standards Organization; JCAHO, Joint Commission on Accreditation of Healthcare Organizations; VA, Department of Veterans Affairs.
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Many different standards must be developed, tested, and deployed before the CPR can realize its full potential. Standards to facilitate the exchange of health care data are needed now so that clinical data may be aggregated and analyzed to support improved decision making.
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1989. A clinical database management system for improved integration of the Veterans Affairs hospital information system.
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1990. The uniform clinical data set.
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Pp. 121-125 in Proceedings of the Fourteenth Annual Symposium on Computer Applications in Medical Care, ed.
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Washington, D.C.: IEEE Computer Society Press. APPENDIX: THE COMPUTER-BASED PATIENT RECORD SYSTEM VENDOR SURVEY The members of the Institute of Medicine study committee agreed that their deliberations would be enhanced by access to data on commercial clinical information systems and on the perspectives of those who develop and market them.
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From page 92... ...
The survey responses also indicated that direct data entry by patient care practitioners was feasible, resistance to change notwithstanding, provided the CPR system was user friendly and was perceived as improving quality and reducing costs for the hospital, clinic, or practice. Taken together, the survey responses appeared to suggest that the environment is right for the implementation of CPRs in hospitals -- that is, if enough of the system's beneficiaries can be convinced that such a comprehensive system justifies the difficulties of implementation.
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FINDING 4. With the exception of a single software vendor, the industry is moving slowing in solving one crucial problem: ease of data entry.
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