The Computer-Based Patient Record

An Essential Technology for Health Care, Revised Edition

Author: Detmer, Don E.; Steen, Elaine B.; Dick, Richard S.
Publisher: National Academies Press
ISBN: 9780309086844
eISBN Pdf: 9780309578851
eISBN Epub: 9780309175340
Place of publication: United States
Year of digital publication: 1997
Month: October
Pages: 257
DDC: 616
Language: English

Caption

Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions:

Who uses patient records?
What technology is available and what further research is necessary to meet users' needs?
What should government, medical organizations, and others do to make the transition to CPRs?

The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

THE COMPUTER-BASED PATIENT RECORD
Copyright
Preface—Revised Edition
Preface—Original Edition
Acknowledgments—Revised Edition
Acknowledgements—Original Edition
Contents
Commentary
A Progress Report on Computer-Based Patient Records in the United States
- THE CHANGING HEALTH CARE LANDSCAPE: REINFORCING THE NEED FOR CPRS
  - The Evolving Role of Primary Care
  - The Integrated Delivery System
  - Technological Advances
    - The Internet and the World Wide Web: Widespread Connectivity
    - World Wide Web Browsers: A Universal View on the Internet
    - The Intranet
    - Network-Centric Computing
- THE CURRENT STATE OF CPRS
  - The CPR Market
    - Integrated View of Patient Data
    - Access to Knowledge Resources
    - Physician Order Entry and Clinician Data Entry
    - Integrated Communications Support
    - Clinical Decision Support
  - At the Fork
  - Recent Activity to Advance CPRs in the United States
  - Remaining Barriers or Challenges
    - Definition of the CPR
    - Meeting User Needs
    - Standards
    - Legal and Social Issues
    - Costs and Benefits
    - Leadership
- CONCLUSION
- ACKNOWLEDGMENTS
- REFERENCES
Commentary
A Progress Report on Computer-Based Patient Records in Europe
- THE CURRENT STATE OF CPRS IN EUROPE
- CPR SYSTEMS IN PRIMARY CARE
  - Role of GPs
  - Training
  - Structure of Health Care
  - Population-Based Care
- CPR SYSTEMS IN HOSPITALS
  - Platforms for CPRs
  - Integrated CPRs
    - CPR Data Entry
  - Natural Language Processing
  - Structured Data Entry
- CPR SYSTEMS FOR SHARED CARE
  - CoCo
  - Diabcard
- USE OF CPR DATA
  - Critiquing a Physician's Care
- INTEGRATION OF PROTOCOLS WITH CPR SYSTEMS
  - Review of CPR Databases
- ADDRESSING BARRIERS
  - Privacy and Confidentiality
  - Standardization
  - Electronic Health Care Record Architecture
  - Coding Systems for Drugs
  - Syntax for Health Care Data Interchange
  - Exchange of Medical Images and Related Data
  - User Identification
- CONCLUSION
- REFERENCES
Summary
- USER NEEDS AND SYSTEM REQUIREMENTS
- COMPUTER-BASED PATIENT RECORD TECHNOLOGIES
- NONTECHNOLOGICAL BARRIERS
- RECOMMENDATIONS
1 Introduction
- THE STUDY
  - The Committee's Charge
  - Committee Activities
  - Definitions
- REPORT ORGANIZATION
- THE PATIENT RECORD
  - Strengths and Weaknesses of Paper Patient Records
    - Problems with Patient Record Content
    - Problems with Format
    - Problems with Access, Availability, and Retrieval
    - Problems with Linkages and Integration
    - Outpatient Records
- INFORMATION MANAGEMENT CHALLENGES
  - An Information-Intensive Industry
  - An Information Explosion
  - Increasing Demand for Data
  - Maintaining Confidentiality
- INFORMATION MANAGEMENT OPPORTUNITIES
- BEYOND TECHNOLOGY
- WHY NOW?
- REFERENCES
2 The Computer-Based Patient Record: Meeting Health Care Needs
- DEFINING HEALTH CARE NEEDS
  - Patient Record Users
  - Patient Record Uses
- TRANSLATING CUSTOMER NEEDS INTO SYSTEM REQUIREMENTS
  - Patient Record Functions
    - Storage
    - Guidance of Clinical Problem Solving
    - Practitioner Support
  - Implementation and Operation Issues
- THE FUTURE PATIENT RECORD
- REFERENCES
3 Computer-Based Patient Record Technologies
- TECHNOLOGICAL BUILDING BLOCKS FOR CPR SYSTEMS
  - Databases and Database Management Systems
    - Databases
    - Database Management Systems
  - Workstations
  - Data Acquisition and Data Retrieval
    - Data Acquisition
    - Data Retrieval
  - Text Processing
  - Image Processing and Storage
  - Data-Exchange and Vocabulary Standards
  - System Communications and Network Infrastructure
  - System Reliability and Security
  - Linkages to Secondary Databases
- EXPERIENCE WITH CPR SYSTEMS
- AN OVERVIEW OF CPR SYSTEMS
  - Physician Offices and Group Practice Settings
    - The Medical Record
  - Health Maintenance Organizations
    - Computer-Stored Ambulatory Record Systems
  - Single Hospitals or Medical Centers
    - Theresa System
    - Health Evaluation Through Logical Processing
    - Beth Israel and Brigham and Women's Hospital System
    - Lockheed's Early Clinical Information System
  - Large Multihospital Systems
    - Department of Veterans Affairs
    - Department of Defense
  - International Developments
    - The Exmouth Project
  - Selected Emerging Developments
    - Chart Checker
    - Problem-Knowledge Coupler
    - Medical Logic Modules
- CLINICIAN INTERACTION AND RESISTANCE
- TECHNOLOGICAL BARRIERS
  - The Human Interface and System Performance
  - Text Processing
  - Confidentiality and Security
  - Health Data-Exchange Standards
- SUMMARY
- REFERENCES
- Appendix: the Computer-based Patient Record System Vendor Survey
  - GENERAL OBSERVATIONS
  - SURVEY FINDINGS
4 The Road to CPR Implementation
- DEVELOPMENT AND DIFFUSION FACTORS
  - Barriers to Development
    - Patient Record Definition
    - Content and Format Standards
    - Costs and Risks
  - Barriers to Diffusion
    - Environment of the Health Care System
    - Leadership
    - User Behavior, Education, and Training
    - Costs
    - Legal and Social Issues
    - Network Needs
- ELEMENTS OF AN IMPLEMENTATION STRATEGY
  - Change Agents and Stakeholders
    - Health Care Professionals and Professional Associations
    - Patients and Representatives of Patients
    - Provider Institutions
    - Third-party Payers
    - Federal Government
    - States
    - Universities and Professional Schools
    - Standard-setting Organizations
    - Vendors
  - Activities and Resources Critical to CPR Development
  - Organizational Structure
    - Federal Agency
    - Private Sector Sponsorship
    - Public-Private Commission or Consortium
    - Preferred Approach
  - Specific Steps for Change Agents
- SUMMARY
- REFERENCES
- Appendix: Maternal and Child Health Care and Computer-Based Patient Records
5 Improving Patient Records: Conclusions and Recommendations
- CONCLUSIONS
- RECOMMENDATIONS
  - Data Acquisition
  - Data and Security Standards
    - Data Standards
    - Security Standards
    - Networking Support
    - Cost-Benefit Analysis
    - Quality Assurance
    - Structure and Format of the Patient Record
- SUMMARY
Appendix A Subcommittees
- USERS AND USES SUBCOMMITTEE MEMBERS
- TECHNOLOGY SUBCOMMITTEE MEMBERS
- STRATEGY AND IMPLEMENTATION SUBCOMMITTEE
Appendix B Legal Aspects of Computer-based Patient Records and Record Systems
- STATE LICENSURE LAWS
  - Hospital Licensure Laws as Barriers to Full Automation
  - Other State Licensure Laws
  - Medicare Regulations
  - Hospital Accreditation Requirements
- PATIENT RIGHTS ISSUES
  - Right of Privacy
  - Right of Access to Health Records
  - Ownership of Patient Data and of the Patient Record
    - Ownership of the Patient Record
    - Rights in Information Contained in the Record
- EVIDENTIARY ISSUES
  - Importance of Admissibility of Patient Records as Evidence
  - Rule Against Hearsay
    - Definition of Hearsay
    - Business Records Exception
    - Best Evidence Rule
- RISKS ARISING FROM COMPUTER-BASED PATIENT RECORD SYSTEMS
  - Breaches of Confidentiality and Unauthorized Access
  - Computer Viruses and Other Computer Sabotage
  - Potential for Inaccessibility
  - Questions of Durability
  - Accuracy Issues
  - Selected Legal Issues in Computer Contracting
- OVERCOMING LEGAL BARRIERS TO COMPUTER-BASED PATIENT RECORDS AND RECORD SYSTEMS
  - Adoption of Uniform National Licensure Standards and Health Information Laws
  - Overcoming Special Legal Risks Related to Computer-based Patient Records
- CONCLUSION
Index