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3 Computer-Based Patient Record Technologies
Pages 100-137

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From page 100...
... 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.
From page 101...
... 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.
From page 102...
... 102 it: Q .
From page 103...
... 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. Although this scenario has a number of advocates and some advantages, it also has several severe problems (Margulies et al., 1989; Hammond et al., 1990~.
From page 104...
... The CPRisso complex that no single database management system is capable of optimally storing and retrieving the full range of patient data (Hammond et al., 1990~. As a result, CPR system developers have used a variety of complementary DBMS s to address these complexities.
From page 105...
... it interferes with the decision maker's ability to use linked databases and other on-line knowledge bases designed to assist health care professionals in the clinical decision-making process. Two keys to the success of next-generation CPR systems are ease of use and proper incentives for data entry at the data source (Young, 1987; Safran et al., 1989~.
From page 106...
... Customizing data in this way is a difficult capability to implement but will produce a system that is much more attractive to end users. 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.
From page 107...
... 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)
From page 108...
... 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.
From page 109...
... 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.
From page 110...
... clinical information on large populations of patients will support their development of policy strategies and general assessments of quality and outcomes of care. Hundreds of databases are available or are now evolving; some of these resources should be linked with the CPR to provide clinical decision support when needed.
From page 111...
... 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)
From page 112...
... Medical computer applications which meet operational criteria are rare except for routine business applications.... 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.
From page 113...
... 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.
From page 114...
... Physician Offices and Group Practice Settings The Medical Record For more than 20 years, the Duke University Medical Centers has been developing a comprehensive medical information system known as The Medical Record (TMR)
From page 115...
... system, which became one of the first systems capable of producing a computer-based patient recorded 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 (Barrett, 1984)
From page 116...
... 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)
From page 117...
... have been collected; the patient record includes data on the individual's medical history, physical examination, and diagnosis, as well as orders, results, progress notes, and physician and nursing notes. The system maintains a lifelong record and never deletes clinical data.
From page 118...
... HELP's primary objective is to provide medical decision support, but it is also a computer-based patient record system. 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.
From page 119...
... 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~.~4 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. More than 800 and more than 1,250 on-line terminals currently operate at Beth Israel and Brigham and Women's hospitals, respectively (Safran et al., 1989~.
From page 120...
... The VA's DHCP consists of software grouped into three categories: (1) that 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.
From page 121...
... Administrative management software supports all normal hospital administrative tasks, including scheduling. Clinical management software supports clinical information provision in the laboratory, pharmacy, and other departments.
From page 122...
... 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. Outsmart cards are electronic devices (usually encased in plastic)
From page 123...
... Further, they indicate the very real need for greater international cooperation in formulating future health care data standards. Selected Emerging Developments Once a patient's clinical data are in machine-readable form, many decision-making aids will be available to health care professionals to permit them to take advantage of the latest information on problems specific to the patient.
From page 124...
... This software is representative of many clinical decision support systems that can be expected to evolve in the near future. Such tools cannot be used by health care professionals, however, until clinical data are captured in machine-readable form.
From page 125...
... The Arden syntax is designed to facilitate the sharing of medical knowledge and is especially well suited for the transfer of medical knowledge bases among disparate medical decision support systems. Clinical data derived from operational CPR systems will contribute significantly to the body of medical knowledge used by future medical decision support systems.
From page 126...
... As we move further into the 1990s, the major technological barriers to widespread implementation of the CPR include problems with text processing, the lack of appropriate confidentiality or security measures, and inadequate health data-exchange standards. The Human Interface and System Performance The lack of sufficiently powerful computing systems at an affordable price has been a major barrier to providing clinicians with an adequate human interface.
From page 127...
... 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)
From page 128...
... 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.
From page 129...
... 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.
From page 130...
... ANA , _ /~ JCAHO 'a: | Other Useful I r | Templates I L _ t~ ] i\~ <' Third-Party\ I \ Payers and J ~ Insurers Template Generation Process ~ , Uniform Clinical Data Set Template /\, CPR System \Vendors \ 1 ~ 1 DoD-to-VA Template Use Data-Exchange Standards to Transfer Set of Clinical Data Defined in Template FIGURE 3-3 Concept of a composite clinical data dictionary.
From page 131...
... 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.
From page 132...
... 1989. A clinical database management system for improved integration of the Veterans Affairs hospital information system.
From page 133...
... 1990. The uniform clinical data set.
From page 134...
... Pp. 121-125 in Proceedings of the Fourteenth Annual Symposium on Computer Applications in Medical Care, ed.
From page 135...
... 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.
From page 136...
... 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.
From page 137...
... 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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