The Computer-Based Patient Record An Essential Technology for Health Care, Revised Edition (1997) / Chapter Skim
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4 The Road to CPR Implementation
4 The Road to CPR Implementation
Pages 138-175
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From page 138... ...
It then presents the committee's plan for addressing these factors. The plan includes a discussion of the various organizations that have a role to play in CPR development and diffusion, the types of activities that would facilitate patient record development, how such activities might be implemented, and when such activities should take place.
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From page 139... ...
Understanding the diverse set of CPR user needs requires that representatives of all users be involved in a process of setting priorities for system functionality and performance. has discussed in Chapter 1, the committee's definition of a CPR is an electronic patient record that resides in a system specifically designed to support users through the availability of complete, accurate patient data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.
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Defining a core set of data elements requires participation by representatives of all patient record user groups. (Exclusion of any group could diminish the efficiency to be gained from implementing CPR systems if, as a result, key data elements are excluded from the core data set.)
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Furthermore, no cost data are available on the monetary investment that might be required to implement such a system; evaluations of cost data related to computer applications tend to have focused on medical information systems (MIS s) rather than on CPR systems.
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. Other factors also affect CPR adoption and use, including the environment of the health care system; leadership; user behavior, education, and training; costs; social and legal issues; and network needs.
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It should also substantially improve patient care processes, for example, by providing clinical decision support or by giving complete record access to authorized personnel. Leadership Given the fragmented environment of the U.S.
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CPR implementation requires experts who can support CPR users, but at present only a relatively small number of individuals have the necessary expertise in medical informatics (Clepper, 1991~. More people must be encouraged to enter this field and a variety of educational and training
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In addition to education, practitioners need incentives to use CPRs to enter data and maintain patient records. Perhaps the greatest motivation for practitioners to use CPRs would be to produce evidence that CPRs can help to improve the quality of patient care and reduce the administrative burdens they currently face.
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This cost analysis illustrates another major difficulty faced by health care provider institutions deciding on acquisition of a CPR system. Decisions about whether to acquire technology are based in part on information about the benefits of the technology; once again, data on CPR system benefits are sparse.
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Hospital licensure laws and regulations in some states still assume a paper patient record, which makes the legal status of CPR systems unclear. Other state laws and regulations appear to permit use of some forms of automation but not others, or the use of automation for some, but not all, patient record functions.
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A consistent personal identification number (PIN) in all patient records would facilitate record linkage across time and provider institutions (National Center for Health Statistics, 1990; Washington Business Group on Health, 1989~.
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For that reason, Appendix B discusses legal aspects of computer-based patient records and record systems. Among the more critical legal aspects addressed there are regulatory and accreditation issues, evidentiary issues, patient privacy and record access concerns, record ownership questions, legal risks attached to specific CPR systems, and computer contracting issues.
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As such, it is a model for the kind of infrastructure needed to transmit patient record data routinely. Given the 7In 1969 the Defense Advanced Research Projects Agency (DARPA)
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Change agents are individuals or organizations who have, first, a mandate related to or significant interest in CPR implementation and, second, the resources or means for effecting a change (e.g., leadership position, regulation, funding)
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152 THE COMPUTER-BASED PATIENT RECORD TABLE 4-1 Change Agents and Stakeholders Important to the Implementation of Computer-based Patient Record Systems Change Agent/Scope Organization of Influence Stakeholder Public Sector Agency for Health Care Policy and Research Yes/national Yes Centers for Disease Control No Yes Congress Yes/national Yes Department of Defense Yes/national Yes Department of Veterans Affairs Yes/national Yes Food and Drug Administration No Yes Health Resources and Services Yes/national Administration Yes Health Care Financing Yes/national Administration Yes National Institutes of Health No Yes National Library of Medicinea Yes/national No State health agencies Yes/regional Yes State legislatures Yes/regional Yes Private Sector (computer standards organizations Computer-based patient record vendors Health care professionals Joint Commission for Accreditation of Healthcare Organizations Patients Patient groups Professional associations Professional schools Provider institutions Researchers Third-party payers Universities aA specific agency of the National Institutes of Health. Yes/national Yes/national Yes/individual Yes/national No Yes Yes No No Yes Yes/local to national Yes Yes/national Yes Yes/regional to national Yes Yes Yes Yes Yes Yes/local No Yes/local to national Yes/regional to national Health Care Professionals and Professional Associations Health care professionals bear a dual burden: they must learn to use a new technology, and they must change their behavior.
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Given patient concerns about privacy and the potential for CPR systems to increase information flow within and outside of health care provider settings, patients may distrust CPR systems. Furthermore, patients are no more likely than health care professionals to use or understand computers, let alone computer-based record systems.
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By purchasing a CPR system, provider institutions can influence CPR development and implementation in three ways. First, such action signals the market that demand for CPR systems exists.
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and the FDA could each benefit from the implementation of CPR systems in two ways. First, CPR implementation would likely improve patient data for epidemiological research.
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The agency is currently developing a computer-based patient record abstracting system, the Uniform Clinical ~HRSA uses two main types of funding. The majority of support is awarded to state health agencies through MCH block grants that are intended to enable states to ensure access to maternal and child health services for low-income individuals and individuals who live in areas of limited health resources.
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Widespread use of CPR systems can be expected to benefit both departments by expanding the availability of technology to meet patient care, research, and education needs. For example, with the CPR, the VA can improve its ability to coordinate health care services provided to veterans in both VA and non-VA settings.
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In the committee's judgment, better patient records are essential to achieving Congress's health care objectives. Consequently, the central role of the CPR in improving patient records and enhancing quality of care, in managing costs, in facilitating Medicare claims processing, and in improving available data for clinical and health services research must be made clear.
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They have played important roles in developing regional databases to monitor quality, manage costs, and assess clinical effectiveness.~4 State governments, cabinet-level health officers, and groups such as the National Conference of State Legislators, Council of State Governments, Association of State and Territorial Health Officials, and National Association of Health Data Organizations could provide a regional perspective in national CPR efforts. In addition, states would be likely candidates for pilot regional studies or experimental prototypes.
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IAIMS sites may also provide an infrastructure on which to base selected pilot CPR demonstration projects. Standard-setting Organizations Two kinds of standard-setting organizations are potential CPR change agents.
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coordination of resources and support for CPR development and diffusion; (7) coordination of information and resources for secondary patient record databases; and (8)
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through enhancements to existing databases similar to the approach AHCPR is currently pursuing for research. Organizational Structure Health care providers spend large amounts of money on computer and software systems that may not meet their needs today and that will not meet their needs tomorrows Complete, accurate, accessible patient care data are needed now for clinical care and research.
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· Define priorities and criteria for CPR demonstration projects that could be used by federal agencies, private foundations, and health care provider institutions. · Conduct workshops and conferences to educate health care professionals and policymakers.
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Although HCFA would be a key beneficiary of widespread CPR implementation and hence likely to want to provide into address this issue fully, the committee organized a one-day workshop in September 1990 to evaluate the feasibility and desirability of alternative organizational models for a CPR organization; AHCPR provided separate funding for the meeting. Workshop participants included representatives of health care professionals, provider institutions, federal agencies, insurers, employers, and private foundations.
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and Veterans Affairs (VA) are both making significant investments in comprehensive medical information systems.~7 As a result, they have a great deal of expertise in designing and implementing such systems.
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It is essential that practitioners view the CPR as a valuable resource for improving patient care. Thus, CPR efforts must involve health care providers as well as federal agencies.
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, which made two recommendations to the secretary of Health and Human Services. First, as part of DHHS's mandate to conduct research on outcomes of health care services, the secretary should "direct the Public Health Service, through its Agency for Health Care Policy and Research, to support the exploration of ways in which automated medical records can be used to more effectively and efficiently provide data for outcomes research" (GAO, 1991:26~.
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· Health care business coalitions, chambers of commerce, and major employers could all support CPR development and implementation efforts by supporting research and pilot demonstrations as well as by developing relationships with insurers and health care provider institutions that use or support CPR systems. · Federal agencies could provide substantial funding for research and development and support standards development through funding or regulatory mandate.
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From page 169... ...
Working groups could study the relationships among referring physicians and among other providers to understand their entire system of health care. They could also define needed data elements, educate local health care professionals on health care information management issues, and monitor progress in the development of standards for security and data exchange.
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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. Anderson, J
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1991. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care.
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1988. Computer-stored medical records: Their future role in medical practice.
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APPENDIX: MATERNAL AND CHILD HEALTH CARE AND COMPUTER-BASED PATIENT RECORDS As discussed in Chapter 3, much of the progress to date in implementing CPRs and CPR systems has occurred in hospitals and large multispecialty practices, particularly in health maintenance organizations. To be successful, however, CPRs and the larger computer-based systems in which they function must be useful and practical for many other types of providers, including, for instance, community-based clinics and other outpatient facilities serving either primary care or special health care needs.
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for both clinical and administrative purposes, they will considerably simplify the reporting requirements of these programs. Moreover, the expectation is that CPR systems ultimately will communicate with each other with the aid of a composite clinical data dictionary (CCDD)
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Lessons from their efforts to date may prove helpful in planning computer-based systems to serve MCH needs; conversely, issues that arise in planning for and delivering services to disadvantaged MCH populations might be posed to DoD and the VA as a means of bringing difficult technical questions to their attention. In addition, the Health Care Financing Administration (HCFA)
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