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1 Introduction
Pages 52-73

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From page 52...
... A 1991 General Accounting Office (GAO) report on automated medical records identified three major ways in which improved patient records could benefit health care (GAO, lithe committee uses the term practitioners to refer to all health care professionals who provide clinical services to patients.
From page 53...
... Thus, this report generally will refer to what are commonly called medical records as "patient records." There are several instances, however, in which the committee continues to refer to medical records rather than patient records. For example, the committee's official charge relates to medical records, and the committee has not undertaken to rename "medical record professionals."
From page 54...
... In addition to addressing the technological issues in its charge, the com mittee 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.
From page 55...
... · A primary patient record is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions. · A secondary patient record is derived from the primary record and contains selected data elements to aid nonclinical users (i.e., persons not involved in direct patient care)
From page 56...
... A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information.
From page 57...
... They are created and used most frequently in health care provider settings such as physician or dentist offices, hospitals, nursing homes, and public health clinics; but other institutions such as correctional institutions, the armed forces, occupational health programs of employers, and colleges and universities also maintain patient health care records (Westin, 1976~.6 For more than a century, the paper patient record has been the primary vehicle for recording patient care information (Huffman, 1981~. Yet recent years have seen a trend toward automation of components of patient records (e.g., clinical laboratory test results)
From page 58...
... "No one has a monopoly on the problem: medical records appear to be equally bad and dangerous throughout the land" (Pories, 1990:47~. He is not alone in his view that patient records often lack the features needed for their most beneficial use.
From page 59...
... .~AVll~l~ ~1 ~l~VlUOl5, OK Of sranuaralzallon of definitions of terminology, failure to describe the patient experience, lack of patient-based generic health outcome measures, and incomprehensibility for patients and their families. Problems with Format Several studies have pointed to patient record formats ~c ~ Rolls ^ Chef ~+ I: :~ _ ~ 1 Aft at t1111~5 1~lpeaes record use and effectiveness.
From page 60...
... Purpose Sample Findings Evaluate record availability, missing data, recording of labo ratory results, incomplete physician narrative, and data collected for general health evaluations 1,149 patient visits in five outpatient U.S. Army facilities 1 1% 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)
From page 61...
... (1988) Purpose Sample Findings Assess the reliability of data collected as part of the National Hospital Discharge Survey 3,313 medical records from 66 hospitals that participated in the National Hospital Discharge Survey 75% of face sheets had no discharge disposition 48% of face sheets were inadequate for determining · .
From page 62...
... 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.
From page 63...
... Clinicians obtain and record information about patients, consult with colleagues, read scientific literature, select diagnostic procedures, interpret results of laboratory studies, devise strategies for patient care, instruct allied health professionals, discuss care plans with patients and families, and document the progress of patients. In addition, health care practitioners must distill knowledge, interpret data, apply knowledge, and manage the complexities of medical decision making (Haynes et al., 1989; Greenes and Shortliffe, 1990~.
From page 64...
... , more kinds of clinical data elements arising from new diagnostic technologies, and developments in the delivery system that result in many patients receiving care at multiple sites. Concomitant with increases in information, however, have been efforts to reduce unit costs of health care provider institutions, which create pressures on health care professionals to be more productive and to see more patients.
From page 65...
... Managers of provider institutions seek to link financial and patient care information to develop meaningful budgets, measure productivity and costs, and evaluate market position. Long-term institutional planning for personnel recruitment, equipment acquisition, and facilities development depends on anticipated trends in patient population needs.
From page 66...
... to enhance "the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad Alone expert has suggested that "[w] hat 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, 1988:1 12)
From page 67...
... 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) Council on Ethical and Judicial Affairs (1989~.~3 Thus, a significant challenge in creating future patient record systems is to achieve an appropriate balance between confidentiality and access by users with a need to known Privacy is the right of individuals to be left alone and to be protected against physical or psychological invasion or the misuse of their property.
From page 68...
... 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
From page 69...
... WHY NOW? Many attempts have been made over the years to advance clinical computing, to reform the patient record, and to encourage health care professionals to maintain the record more conscientiously (e.g., by entering necessary clinical data)
From page 70...
... 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.
From page 71...
... 1991. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care.
From page 72...
... 1937. Medical Records in the Hospital.
From page 73...
... 1975. Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters.


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