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Institute of medication (US) Committee on enhancing the patient Record; prick RS, Steen EB, Detmer DE, editors. The Computer-Based patience Record: amendment Edition: crucial Technology for wellness Care. Washington (DC): nationwide Academies push (US); 1997.


The Computer-Based patience Record: modification Edition: crucial Technology for health and wellness Care.

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Institute of medication (US) Committee on boosting the patience Record; penis RS, Steen EB, Detmer DE, editors.

In recent years, computerization of patient records has actually increased at a middle rate and also this tendency is likely to continue, specifically as technology improves and becomes more affordable and as the need for health treatment information increases. If future patient records are merely automated versions of most present records, however, an opportunity to enhance a an essential resource because that health care will have actually been lost. For example, in the patient record of the future, the committee seeks the ability to accessibility quickly a list of present problems, a trace of clinical logic, the patient"s wellness status, and the most recent information about various treatment alternatives for the patient"s condition. Easy accessibility to and sound company of data facets can be listed by automation of patient records, but the ease of access of the data elements depends on even if it is practitioners collect and also record together data in the very first place. Further, accessibility to bibliographic and knowledge databases will require new functions not provided by classic patient records.

Thus, the automation of patient record retrieval, maintenance, and use is necessary, however not sufficient, for document improvement. Provided existing and emerging computer technologies and the evolving nature of health and wellness care, the committee believes that the patient document can, must, and will build to meet the expanding needs of the health care field. This chapter identifies the attributes of future patient records that are compelled to satisfy these needs, stating several of lock in detail to highlight the scope and complexity the the problems to it is in addressed.

Defining Health treatment Needs

The quality of a patient document or a patience record system depends ~ above its ability to satisfy the needs and requirements that those who use it. As discussed below, those users include, however are not restricted to, physicians and nurses delivering care to patients. The committee complied with three steps suggested by the continuous quality innovation model to build its vision that an improved patient record and also record system: (1) determine the customers; (2) recognize their requirements; and also (3) analyze those requirements into functional features of the system (Donabedian, 1966, 1988; Batalden and Buchanan, 1989; Berwick, 1989). 1

Patient record Users

The committee generally defined the customers of patient documents as those individuals who enter, verify, correct, analyze, or attain information native the record, either straight or v an intermediary. All individuals of the patient record eventually support patience care. Castle differ, however, in how and also why they usage the record.

Some users have daily call with the record, others access the record sporadically, and also still others never ever actually handle the record yet rely top top data derived from it. An exhaustive perform of patient document users would essentially parallel a perform of the individuals and also organizations connected directly or indirectly through the supplication of wellness care. Patient document users provide, manage, review, or reimburse patient treatment services; conduct clinical or wellness services research; education health treatment professionals or patients; construct or control health treatment technologies; accredit health care professionals or provider institutions; and make health treatment policy decisions. Every one of these type of users are ""customers" of the patience record, and also their needs need to be met by patient document systems the the future.

Users space individuals, however they most frequently perform their attributes on instead of of institutions. Box 2-1A and 2-1B identify species of individuals and also organizations that rely on patient records or the data castle contain. These lists room illustrative quite than an extensive and show the wide selection of users and also settings in i m sorry patient records are employed.

BOX 2-1A

REPRESENTATIVE INDIVIDUAL users OF patient RECORDS. Patient care Delivery (Providers) Chaplains

Primary offers of patient documents are connected with the supplication of patience care, that is, with providing, consuming, managing, reviewing, supporting, and also charging and also reimbursing patient care services. Secondary uses the patient records are not thought about necessary for a particular encounter between a patient and also a health treatment professional, but such uses affect the setting in which patient treatment is provided. Education, research and development, regulation, and also policymaking are all considered secondary uses of the patient record.

Practical considerations compelled the committee to focus on particular high-priority record supplies rather than on all possible functions of the record. The four major categories of patient record uses taken into consideration by the committee were straight patient care, management and management, reimbursement, and also research.

Translating client Needs right into System Requirements

Proper device design way achieving a patient record mechanism that correctly fits, interacts with, and also communicates in the accepted manner of every user ar the system supports. This kind of design is vital if automatic patient document systems room to be embraced by users. The committee identified the needs of patient document users in regards to system duty and problems of implementation and operation. System function is what the system permits users come do and also what it does because that them. Implementation and operation problems relate come the factors users think about in acquiring and installing a system. These determinants are crucial regardless of the form of the record (e.g., paper or computer-based).

The specific features users look for in patient records and also record systems room described below in terms of the computer-based patient record (CPR). Most of these preferred features are usual to 2 or more significant kinds of record users. Unique involves or requirements of a user team are additionally identified. Crate 2-3 presents review of user requirements.

BOX 2-3

USER demands FOR patience RECORDS and also RECORD SYSTEMS. Document Content Uniform core data elements

In translate in the list of user requirements, the committee provided two distinct considerations. First, user needs can problem with every other—not just amongst groups (e.g., patients and also practitioners need confidentiality, however claims payers seek access to in-depth clinical information), but additionally within a solitary user group (e.g., medical professionals want accessibility to information to be very fast, but they may additionally want to have the ability to sort info according to complex logical rules, i beg your pardon slows an answer times). Come the degree possible, the committee resolved such disputes by using cautious rules that priority. In number of cases, however, the conflicts remained nettlesome and also are discussed in chapter 4 as certain challenges to future patient record development.

Second, at a technological frontier, customers may have an obstacle expressing or also imagining a need. This instance may well occur with the computer-based patience record, i m sorry contains avenues for functional attributes that many users would not think come request. The pioneering designer should not only ask, "What do civilization want?" yet also, "What would human being want if castle knew what might be done for them?"

Patient document Functions

The traditional duty of patient records has actually been to store info relevant come the care of a patience for succeeding retrieval. Patient record systems must offer individuals at least two additional functions. First, records should have the ability to guide the process of clinical trouble solving. Second, records should support clinicians v decision analysis, reminders, risk assessment, and also other "intelligent" features not available with paper records.


The attributes connected with the storage function are record accessibility (i.e., availability, convenience, speed, and also ease the use), quality, security, flexibility, connectivity, and efficiency.

ACCESS very first and foremost, users want come retrieve information conveniently when and where they need it. Other functions of a patient record system are essentially irrelevant to customers if they cannot gain accessibility to the system, to the documents in the system, or to the data in the records.

Access can be described in regards to availability, convenience, reliability, 3 and ease that use. A patience record system should permit authorized clinical customers convenient access to any type of record 24 hours a day. This requirement indicates an adequate variety of conveniently located terminals or work-stations, no mechanism downtime, no shed records or data, and access to the document by an ext than one user at the same time. Nonclinical users typically require access to patient record data in ~ least throughout standard functioning hours.

Different customers need various levels and also kinds of details (see box 2-4). The ease through which users find or retrieve needed data facets depends largely on the record format. Current record record styles tend come segregate quite than integrate information; come facilitate interaction of required information, an combined format is necessary. Thus, records need to contain a front-page trouble list to enable users come locate wanted information. In addition, document systems should enable users to "flip through" or conveniently scan records; a table of materials or index would certainly be valuable for this purpose.

BOX 2-4

DIFFERENT customers NEED different LEVELS and also KINDS of DATA. A patient document database has many data elements, and each user community has a unique, definable "view" the the database the brings with each other the elements needed by that community. (Some areas (more...)

Several various other capabilities are required for optimal access. Customers should be able to display information at various levels of detail. Moreover, the device should permit practically every data item come be supplied as a key for retrieval and also should also permit users to accessibility subsets that data. Every users, nevertheless of your level of computer expertise, should have the ability to enter many queries there is no the intervention of a programmer; thus, an English-like retrieval language need to be component of the system.

Accessing details when needed includes more than recognize an easily accessible terminal; native the user"s allude of view, it way an sufficient (i.e., fast) system response time. Individuals want to perform their work at the very least as quick as they at this time perform castle with file records. Exceptionally rapid retrieval the information, measured in fractions of a second, is an essential function for primary users the the CPR. In addition, clinicians, who are accustomed to creating or dictating your entries to patient records, desire a comparable method in the CPR system to add data to the record.

From the users" perspective, the challenge involved in finding out to usage a system additionally affects access. Thus, operation of patient record systems must require just minimal training.4 maintain for medical professionals in particular should be short and also easy, preferably emerging "on line" and also at their convenience. Countless physicians are unwilling to devote big blocks the time to finding out a new record system, also if at some point it might make their work easier. In addition, built-in, displayable "help" documentation on device operation and also the data elements should be easily accessible to both clinical and nonclinical users.

The question of patient accessibility to records is debated amongst practitioners. It is likely, however, the the tendency toward raising patient accessibility will continue. Some providers take into consideration it suitable for patient to enter data (e.g., historic medical information) right into their documents routinely. Recently, useful status and also preferences among various treatments have been figured out as data that could be videotaped by patient to assist practitioners in emerging care plans.

Some practitioners encourage patients to audit their documents for accuracy and also completeness; castle may likewise use the record for patience education. Indeed, as patients come to be increasingly computer-literate, knowledge-seeking consumer of health treatment services, the CPR may function as vital patient education and learning tool by giving patients access to resources such as MEDLINE.

DATA high quality The notion of data quality has several attributes: legibility, accuracy, completeness, and meaning. CPR systems eliminate the require for handwriting and also thus enhance legibility. Accuracy that CPRs deserve to be enhanced by data entrance screens and also logical rules the flag or block unreasonable entries for particular data fields. Come the level that CPRs reduce the need for one intermediary to enter data (i.e., because that transcription), a potential resource of errors (and cost) is removed. When errors carry out occur, for legal purposes the original entry and the correction have to both be preserved (Waller, in this volume). Data accuracy additionally has effects for the security and also reliability the CPR equipment insofar as the systems need to ensure that data room not lost or unknowingly corrupted.5

The completeness the patient records for subsequent users counts in part on agreement amongst users about uniform main point data elements. Without together uniformity, what one patient record user views as complete data might be taken into consideration incomplete by another. Data completeness indicates that systems will accommodate the right now expected variety and intricacy of clinical data and also that they will certainly permit brand-new data fields to be included and useless data areas to be identified.6

For patient records to meet user needs, patience problems and also the current status the patient troubles should be clearly noted in the record. In addition, that is necessary that the health treatment provider"s rationale because that clinical decisions be plainly documented. Lack of a recorded rationale hinders the capacity of succeeding users the the document to make suitable judgments concerning patient care, high quality assurance, utilization review, reimbursement, and also research.

For purposes of wellness services research, patient wellness status is the single most essential data element that is usually lacking from the patient records of today. Formal, interpretable info on health and wellness status is a precondition both to case mix or risk factor adjustment and also to evaluate of the outcomes that care. The research community plainly wants wellness status information, collected in a traditional format, to it is in a routine component of the record of the future. Such records have to also file health risk components (e.g., smoking).

Technology assessment, clinical investigation, and also health services research have been slowed by the absence of reliable, valid, standardized, consistently gathered information ~ above the health and wellness status and also functional level of patient (Ellwood, 1988; Roper et al., 1988). Moreover, practitioners may advantage from routine access of health status measures. Some evidence suggests that without such measurements in regimen clinical practice, physicians and also other health care professionals often overlook far-reaching impairments and changes in duty among your patients (Nelson, 1990). In the previous two decades, numerous health solutions researchers have worked to develop, test, and also refine health status procedures with sound psychometric characteristics (Katz, 1987; Lohr and also Ware, 1987; McDowell and also Newell, 1987; Lohr, 1989). These type of methodological breakthroughs could significantly increase the handy application of standardized health and wellness status data.

The committee recognized that the question of whether and also how soon health and wellness status assessment will influence the top quality of treatment remains to it is in addressed. To get a better understanding that the worth of health and wellness status measures, the committee sustained their widespread fostering as a ingredient of the patience record—but under problems that would permit testimonial of who they help and the how ideal they have the right to be employed. The committee did not recognize an optimal set of health status measure up instruments, together this determination was not part of that charge. Rather, to expand the basic of potential compare of case mix, care, morbidity, and also outcomes, the committee noted the potential worth of standardizing or otherwise raising the compatibility that those tools now in typical use.

It remains unclear how outcome data have the right to be gathered and used unobtrusively, inexpensively, and also conveniently enough that such activities will come to be widespread. Just adopting a computerized record style may not overcome the obstacles that so much have bind the diffusion of wellness status measurement right into routine clinical practice. Computerization may make the analysis of such info easier but may not impact its collection.

The completeness of patient documents depends in component on the moment it takes come add brand-new information come the record, as soon as that information is available. Data completeness deserve to be intensified by linkages in between CPR systems and also ancillary equipment (e.g., laboratory, radiology), which permit the move of results from ancillary equipment to the CPR in the hospital, physician"s office, or various other provider setting as soon because of this results room available.

Maintaining the top quality of patience data additionally requires the the data have an interpretation for users. Reliable retrieval and also use of info from patient documents depend ~ above consistency in naming or explicate the same findings, clinical problems, procedures, drugs, and also other data in ~ a solitary patient record, throughout many patient records in a solitary record system, or in various other systems the contain data appropriate to the understanding and treatment of patience problems. Communication amongst practitioners deserve to be aided by a typical clinical data dictionary and also a clinical coding mechanism that space interchangeable any clinical data common to different specialists or professions but particular enough to describe the detailed data distinct to a job or specialty.

Health care researchers have actually a special require for record systems the provide an ext uniform results than are noted by present systems. Continuous description that clinical contents becomes much more important v the aggregation the data from plenty of patient records—as in outcomes research, for example. Standardized data dictionaries, coding schemes, and uniform data set permit an ext complete, reputable analyses of care and an illness patterns including multiple sites.7

SECURITY CPR systems have actually two protection requirements. First, as discussed in thing 1, patient and provider privacy have to be protected. Second, data and software need to be safeguarded versus tampering and also unintentional destruction. This requirements need both system and data defense measures. Mechanism security describes the steps taken to save computer-based details systems safe from unauthorized access and other harm. Data security involves protection that data from accidental or knowingly disclosure come unauthorized persons and from unauthorized alteration.

Data security has both data confidentiality and data integrity. Data confidentiality is a ""requirement whose objective is to save sensitive info from being disclosed to unauthorized recipients" (National research Council , 1991:52). Confidentiality needs appropriate action by physicians, nurses, midwives, secretaries, medical technicians, paramedical staff, social workers, hospital managers, computer staff, and also research investigators in health care facilities come safeguard the privacy of patient information. Confidentiality additionally requires that computer system systems refuse accessibility to innocuous individuals.

In the narrowest sense, data integrity describes the consistency and accuracy that data stored in computer-based systems. The is a "requirement meant to ensure the information and also programs are adjusted only in a specified and authorized manner" (NRC, 1991:54). Data integrity is of paramount prominence to the CPR, and care should be taken, especially in distributed CPR equipment (see thing 3), to ensure that records have the right to be totally restored in the occasion of device failures.

A wider definition that data truth could likewise be accordingly applied to patience data. Data are stated to have integrity if lock comply with an a priori declared expectation that they have actually a defined set of attributes. This a priori set of features is unique to the data, to the process operating top top the data, and to the data holder. Such characteristics might include timeliness (e.g., every data element is post within five minutes of availability), completeness (e.g., a certain set of data elements must be component of the record), and accuracy (e.g., there room no assignment errors, every deal with has a zip code).

Data truth in future patience records might be intensified by including a data validity field that would certainly flag data that can not it is in correct. Data validity would certainly be second parameter versus which integrity could be judged and thereby controlled. Informing subsequent users the an entry can be incorrect would enable them come discount or neglect the information.

FLEXIBILITY individuals assign high priority to adaptability in records; they do not want to be required to use the record in a universally uniform or prescribed manner. Thus, future CPR systems must permit customization the data entrance formats, reporting formats, and display formats—both because that and, in some cases, by particular users. Patient document user requirements are simply too many and also too differed for any type of one combination of input, reporting, or screen options. Furthermore, research study has presented that the capacity to customize computer interfaces according to one"s preferences and work habits increases user accept of computer systems (Bikson et al., 1987).

Conventional styles should it is in designed and accessible as default modes, yet the customers of the patient document of the future should discover the document easy come mold to your individual, neighborhood needs. Various formats because that displaying details on the screen or on record should be available. The document should also permit integration across disciplines and professional specialties and carry out different "views"8 of patience data for different users (see box 2-4).

Flexibility is also required to meet the varied reporting requirements of users, particularly physician specialties. Doctors need record information easily accessible both in easily accessible, typical reporting formats (such as letters, insurance forms, school and camp certificates, etc.) and in styles they can easily customize according to specialty and individual taste. Therefore, the CPR mechanism should save a user-friendly report generator because that physicians and also others that wish to design specialized reports for their own use.

CONNECTIVITY Connectivity denotes the potential of the document or record system to create links or to interact effectively with any kind of sort of provider or database that may enhance the treatment of the patient. Three different interfaces are crucial in together interactions: the interface amongst records or record systems of various provider institutions, the interface between the record and other repositories or potential repositories of information that may be helpful in caring because that the patient, and the interface in between the record and a practitioner.

Linkages among the miscellaneous clinical documents pertaining come a solitary patient are also important to users, who frequently want a longitudinal patience record—records from different times, providers, and also sites of treatment that are connected to form a lifelong watch of a patient"s health treatment experiences. Linkages are also needed to deliver patient data indigenous one care setting to an additional (e.g., from physician office to hospital) to facilitate service coordination.

Linking the documents of household members, or the records of people who received a specific procedure in a particular facility, might prove useful for some types of epidemiological analysis. The aggregation of patient data for large analysis, however, calls for more complex kinds the linkages. Integration of appropriate subsets that data throughout institutional boundaries is particularly important as researchers attempt to know diseases and also episodes of condition independent of the details institution or health care professional through whom patients uncover themselves in ~ a details phase of their illness.

Patient document systems should also offer linkages to various other databases and also other resources of information.9 preferable linkages encompass databases the contain scientific literature and also bibliographic information, governmental information (e.g., coverage for a particular elective procedure for a given insurance plan), clinical practice guidelines, insurance allowance claims, and condition registries.

Connectivity renders several other demands on the device as well. To make it simple for the practitioner to communicate with the record, data entry need to be virtually as straightforward as writing, and also databases need to be organized in together a means that any terminal or microcomputer ~ above the system have the right to retrieve requested data. As listed earlier, communication among practitioners relies on usual data dictionaries and clinical coding systems. To interface conveniently with a database or registry requires a different sort the connectivity. Workstations have to be designed with telecommunications interfaces that enable the user to switch almost instantly between the information in the record and its relevant equivalent in the outside knowledge base.

EFFICIENCY users want to minimize expense, effort, complexity, and waste. To achieve such efficiencies, computer-based patient document systems should include particular capabilities—in particular, one-time data entry and performance of regime tasks. Further, CPR systems need to be designed so that data content is streamlined and also unnecessary data space not collected.

Any data gotten in into the device should be accessible for a variety of uses, eliminating the require for redundancy data entry. (The need for hand-operated extraction of data and also re-entry procedures considerably diminishes the value of a system.) The mechanism should it is in designed come ensure the data are easily accessible to support patient care, organizational operations, and also decision making. Thus, data have to be viewed as an organizational resource, not residential property "owned" or regulated by the departments that take place to collection them or that space the major users of the data.

The CPR mechanism should be a part of an combined patient care information system. If the mechanism is hospital based, that should interact with solution in the clinical laboratory, pharmacy, respiratory tract therapy, various other ancillary services, referring doctor offices, and other care settings (e.g., home, parenting home) so that data will not require hand-operated transcription indigenous one device to another. If the device is based in a physician"s office, it should connect with the computer system systems of regional clinical laboratories, pharmacies, hospitals, and also other physicians" offices.10

CPR systems have to facilitate the movement of data into, within, and also outside that the automated patient record. In particular, they must permit raw and aggregated data come be relocated to another electronic database for further evaluation and storage. For example, a hospital or individual doctor should be able to extract selected details electronically native a patient care database come send come other internal or exterior (perhaps national) databases.11 In addition, the device should have no problem accepting data straight from electronic monitoring devices and other patient treatment equipment.

Health treatment professionals perform plenty of routine administrative tasks in the food of offering services, and they seek means to mitigate this bureaucratic burden so the they have the right to devote more time to straight patient care, research, and education. Patient record systems should administer the capacity to generate regime documents based upon record data automatically, to send insurance insurance claims electronically, and to report adverse reactions or incidents of tracked illness automatically.

Computer-based records should be designed to stop the just replication of file record features and behaviors that, top top reflection, have little or no worth to users. Instances of waste incorporate information that is routinely collected but never used; inflexible, redundant styles for recording data that an outcome in duplicative details (e.g., obsolescent manual medication files); and also retrospective quality assurance that can be replaced with online high quality assurance. Such features and also behaviors include cost rather than top quality to the document system.

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The committee did not specifically investigate the nature or border of such wasted effort in present-day records, yet members shared the basic impression the it abounds. In developing the CPR, time would be well invested in practical research come identify and remove these "non-value-added" steps, features, and data elements, with the intent of producing a document that is leaner, less complex, and much more streamlined than that of today. This process is most likely to require changes in regulation or laws, and the committee urges the such transforms be analyzed, recommended, and adopted (see thing 5).