Computer-Based Patient Record An Essential Technology for Health Care (1991) / Chapter Skim
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INTRODUCTION
INTRODUCTION
Pages 8-29
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report on automated medical records identified three major ways in which improved patient records could benefit health care (GAO, 1The 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.
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Automated patient records can also support decision making and quality assurance activities and provide clinical reminders to assist in patient care. Second, automated patient records can enhance outcomes research programs by electronically capturing clinical information for evaluation.
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In addition to addressing the technological issues in its charge, the committee sought to produce a report that would increase the interest of all health care practitioners in improving patient records and health care information management. Involvement of these practitioners in the development of future patient records is required if record improvement efforts are to meet with success.
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. Traditionally, patient records have been paper and have been used to store patient care data.
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Chapter 4 describes nontechnological barriers to improving patient records and presents a strategic plan for overcoming them. Finally, Chapter 5 sets forth the committee's recommendations for accelerating the realization of computer-based patient records and suggests an agenda for their implementation and dissemination within a decade.
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Information on the medications prescribed and the specialties of the physicians writing the prescriptions can provide enough information to determine a patient's medical problems, however, and pharmacy records may thus raise confidentiality issues similar to those associated with patient records. Because the committee focused more closely on traditional patient care records, this report does not address issues related to pharmacy records.
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In a recent survey of internists in academic and private practice, 63 percent of the respondents agreed with the statement that patient records are becoming increasingly burdensome without improving the quality of patient care (Hershey et al., 1989)
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(In one study of paper patient records, the average weight of a clinic record was 1-1/2 pounds [Rogers et al., 1982]
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Purpose Sample Findings Evaluate record availability, missing data, recording of laboratory results, incomplete physician narrative, and data collected for general health evaluations 1,149 patient visits in five outpatient U.S. Army facilities 11 % of patients had no past medical data available 5-20% of charts had information missing: 75% of missing data were laboratory test results or reports of radiologic examinations 25% of missing data were lost, incomplete, or illegible data from previous visits 13-79% of laboratory results were not placed in the record 10-49% of visits did not have a well-defined problem in the record 6-49% of visits did not have a well-defined treatment in the record 40-73% of records did not have evidence of general medical information useful for preventive medicine Determine presence of 18 data elements 1,628 medical records (the last episode of disease)
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/Parameters Study Data IOM (1980) Purpose Assess the reliability of data collected as part of the National Hospital Discharge Survey Sample 3,313 medical records from 66 hospitals that participated in the National Hospital Discharge Survey Findings 75% of face sheets had no discharge disposition 48% of face sheets were inadequate for determining principal diagnosis 15% offace sheets and discharge summaries were inadequate for determining principal diagnosis Koinm and Putnam (1981)
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Paper patient records offer little hope of improving the coordination of health care services within or among provider institutions. Moreover, the inadequacy of patient record interfaces with other clinical data, administrative information, or medical knowledge impedes optimal use of record information in providing patient care.
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Yet outpatient records are greater in number, are scattered among individual 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.
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. 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)
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according to the institution's patient case mix. Managers of provider institutions seek to link financial and patient care information to develop meaningful budgets, measure productivity and costs, and evaluate market position.
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to enhance "the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad "One expert has suggested that "[wjhat is needed is a new kind of trial, one that combines randomized prescription of approved drugs and hands-off follow-up with recording of medical outcomes and determination of costs from routinely generated computerized patient records" (Paterson, 1988:112)
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All of these activities underscore the vastly increased demand for patient data 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 avoid violating a patient's right to privacy -- is affirmed by the American Medical Association (AMA)
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Computerbased patient records can support information management and independent learning by health care students and professionals in both patient care and clinical research settings. Tools for such learning include clinical decision
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First, current demands for patient information throughout the health care sector will not diminish; indeed, they will probably increase. Second, technologies essential to computer-based patient records are becoming more powerful and less expen15Examination of the role of patient records in the clinical process, as manifested in the debate surrounding the problem-oriented record, has been under way for more than 20 years (Weed, 1968; Goldfinger, 1972; Margolis, 1979)
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Paper prepared for the Institute of Medicine Committee on Improving Patient Records in Response to Increasing Functional Requirements and Technological Advances. American Medical Association Council on Ethical and Judicial Affairs.
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1991. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care.
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1937. Medical Records in the Hospital.
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1975. Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters.
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