The Computer-Based Patient Record An Essential Technology for Health Care, Revised Edition (1997) / Chapter Skim
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2 The Computer-Based Patient Record: Meeting Health Care Needs
2 The Computer-Based Patient Record: Meeting Health Care Needs
Pages 74-99
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From page 74... ...
For example, in the patient record of the future, the committee seeks the ability to access quickly a list of current problems, a trail of clinical logic, the patient's health status, and the most recent information about various treatment options for the patient's condition. Easy access to and sound organization of data elements can be provided by automation of patient records, but the availability of the data elements depends on whether practitioners collect and record such data in the first place.
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From page 75... ...
Patient record users provide, manage, review, or reimburse patient care services; conduct clinical or health services research; educate health care professionals or patients; develop or regulate health care technologies; accredit health care professionals or provider institutions; and make health care policy decisions. All of these kinds of users are "customers" of the patient record, and their needs should be met by patient record systems of the future.
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From page 76... ...
, patients, administrators, thirdparty payers, and researchers.2 Patient Record Uses Just as the range of patient record users includes more than physicians, nurses, and other health care professionals, patient record uses extend beyond direct patient care. Similar to a comprehensive list of users, a complete list of uses would be quite long.
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From page 77... ...
MEETING HEALTH CARE NEEDS 77 Primary uses of patient records are associated with the provision of patient care, that is, with providing, consuming, managing, reviewing, supporting, and charging and reimbursing patient care services. Secondary uses of patient records are not considered necessary for a particular encounter between a patient and a health care professional, but such uses influence
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From page 78... ...
Practical considerations forced the committee to focus on certain highpriority record uses rather than on all possible functions of the record. The four major categories of patient record uses considered by the committee were direct patient care, administration and management, reimbursement, and research.
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From page 79... ...
. The specific features users seek in patient records and record systems are described below in terms of the computer-based patient record (CPR)
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From page 80... ...
First, user needs can conflict with each other not just among groups (e.g., patients and practitioners need confidentiality, but claims payers seek access to detailed clinical information) , but also within a single user group (e.g., doctors want access to information to be very fast, but they may also want to be able to sort information according to complicated logical rules, which slows response times)
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From page 81... ...
The ease with which users locate or retrieve needed data elements depends largely on the record format. Current paper record formats tend to segregate rather than integrate information; to facilitate communication of 3System reliability refers to the constant availability of hardware and software needed for work in the clinical setting.
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From page 82... ...
In addition, record systems should allow users to "flip through" or easily scan records; a table of contents or index would be helpful for this purpose.
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From page 83... ...
4This statement assumes that record users will receive adequate training in how to use patient records and the other functions provided by patient record systems through formal education (i.e., professional schools and continuing education)
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From page 84... ...
. Data accuracy also has implications for the security and reliability of CPR systems insofar as the systems must ensure that data are not lost or unknowingly corrupted.5 The completeness of patient records for subsequent users depends in part on agreement among users about uniform core data elements.
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From page 85... ...
Some evidence suggests that without such measurements in routine clinical practice, physicians and other health care professionals often overlook significant impairments and changes in function among their patients (Nelson, 1990~. In the past two decades, many health services researchers have worked to develop, test, and refine health status measures with sound psychometric characteristics (Katz, 1987; Lohr and Ware, 1987; McDowell and Newell, 1987; Lohr, 1989~.
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From page 86... ...
Consistent description of clinical content becomes more important with the aggregation of data from many patient records as in outcomes research, for example. Standardized data dictionaries, coding schemes, and uniform data sets permit more complete, reliable analyses of care and disease patterns involving multiple sites.7 SECURITY CPR systems have two security requirements.
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From page 87... ...
. Data integrity in future patient records might be enhanced by including a data validity field that would flag data that might not be correct.
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From page 88... ...
Linkages among the various clinical records pertaining to a single patient are also important to users, who often want a longitudinal patient recordrecords from different times, providers, and sites of care that are linked to form a lifelong view of a patient's health care experiences. Linkages are also needed to transfer patient data from one care setting to another (e.g., from physician office to hospital)
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From page 89... ...
databases.~i In addition, the system should have no trouble accepting data directly from electronic monitoring devices and other patient care equipment. Health care professionals perform many routine administrative tasks in the course of providing services, and they seek ways to reduce this administrative burden so that they can devote more time to direct patient care, research, and education.
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From page 90... ...
i2 Studies investigating the use of the problem-oriented format to record the patient care process report three advantages over non-problem-oriented Tithe problem-oriented medical record categorizes clinical information relevant to the medical care of the patient into four functional groups. Clinical data include demographic data, subjective data provided by the patient as clinical history, and objective data elicited either by physical examination or by technical means (e.g., laboratory tests, radiology examinations)
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From page 91... ...
The committee unanimously believes that patient records should guide and reflect clinical problem solving and that the mere translation of current record formats, data, and habits from paper to computer-based systems will not alone produce the range of improvements in care potentially achievable in a truly reformed patient record system. Current systems include behaviors and record forms that produce substantial waste, imprecision, and complexity in a care system less and less able to tolerate that burden.
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From page 92... ...
Currently available patient-specific consultation systems suggest differential diagnoses, indicate additional information that would help to narrow the range of etiologic possibilities, suggest a single best explanation for a patient's symptoms, or provide advice on therapy (Shortliffe et al., 1990~. CPR systems can support practitioners in the patient care setting by providing easy access to knowledge and bibliographic databases.
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From page 93... ...
sorting information in one record or information aggregated across multiple records; (3) aggregating data across patients by hospital, patient care unit, and department; and (4)
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From page 94... ...
First, future patient records must support patient care and improve its quality. Second, they must enhance the productivity of health care professionals and reduce the administrative and labor costs associated with health care delivery and financing.
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From page 95... ...
Physician offices will be able to communicate with local hospitals and with national bibliographic resources such as MEDLINE. In the larger health care environment, computer-based information management systems will be able to communicate with information systems of provider institutions, third-party payers, and other health care entities.
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From page 96... ...
r ~ =~=1 .:.:.:.:.::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 1 _ ................................................................... ' 000 OOOCOO 00000 OCOCO ~Oq=~o o~ 1 pharmacy radiology Administrative, management, and support services and departments admitting finance risk management THE COMPUTER-BASED PATIENT RECORD External Sources or Recipients of Patient Data Other provider institutions hospitals nursing homes physicians' offices Other patient care settings inpatient outpatient (including home health)
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From page 97... ...
MEETING HEALTH CARE NEEDS ~0 I\ if.
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From page 98... ...
can be brought to health care professionals at the time and site of patient care. It also includes providing opportunities for reducing administrative costs associated with health care financing and collecting administrative data for internal and external review.
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From page 99... ...
1989. Advances in health status assessment: Conference proceedings.
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