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


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

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

In current years, computerization of patience records has actually increased in ~ a middle rate and this trend is likely to continue, an especially as modern technology improves and also becomes much more affordable and also as the need for health treatment information increases. If future patient records are just automated versions of most present records, however, an opportunity to boost a an essential resource for health care will have been lost. Because that example, in the patient record of the future, the committee seeks the capability to accessibility quickly a list of existing problems, a trace of clinical logic, the patient"s health status, and also the many recent information around various treatment alternatives for the patient"s condition. Easy accessibility to and sound organization of data facets can be detailed by automation of patience records, however the ease of access of the data elements depends on even if it is practitioners collect and record such data in the first place. Further, access to bibliographic and also knowledge databases will require new functions not detailed by traditional patient records.

Thus, the automation the patient document retrieval, maintenance, and use is necessary, but not sufficient, for document improvement. Given existing and also emerging computer technologies and also the evolving nature of wellness care, the committee believes that the patient document can, must, and also will construct to fulfill the broadening needs of the health care field. This chapter identifies the qualities of future patient records that are compelled to fulfill these needs, pointing out several of castle in information to highlight the scope and also complexity that the concerns to it is in addressed.


Defining Health care Needs

The quality of a patient document or a patience record mechanism depends ~ above its ability to satisfy the needs and requirements of those who usage it. As disputed below, those customers include, yet are not restricted to, physicians and also nurses delivering care to patients. The committee complied with three steps argued by the constant quality development model to construct its vision that an enhanced patient record and also record system: (1) identify the customers; (2) understand their requirements; and (3) interpret those requirements into functional features of the mechanism (Donabedian, 1966, 1988; Batalden and also Buchanan, 1989; Berwick, 1989). 1


Patient document Users

The committee extensively defined the users of patient records as those people who enter, verify, correct, analyze, or attain information indigenous the record, either directly or with an intermediary. All users of the patient record eventually support patience care. Castle differ, however, in how and why they usage the record.

Some users have actually daily call with the record, others access the record sporadically, and also still others never actually handle the record but rely on data acquired from it. An exhaustive perform of patient document users would essentially parallel a list of the individuals and organizations linked directly or indirectly through the provision of health care. Patient document users provide, manage, review, or reimburse patient treatment services; command clinical or wellness services research; educate health care professionals or patients; construct or regulate health care technologies; accredit health treatment professionals or provider institutions; and make health care policy decisions. All of these type of users room ""customers" that the patience record, and also their needs have to be met by patient record systems of the future.

Users are individuals, but they most commonly perform their features on behalf of institutions. Box 2-1A and also 2-1B identify varieties of individuals and also organizations that depend on patient documents or the data lock contain. These lists space illustrative rather than an extensive and suggest the wide selection of users and settings in i beg your pardon patient records are employed.



BOX 2-1A

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





Primary supplies of patient documents are linked with the supplication of patience care, that is, with providing, consuming, managing, reviewing, supporting, and charging and also reimbursing patient treatment services. Second uses that patient documents are not thought about necessary because that a certain encounter in between a patient and a health treatment professional, but such uses influence the setting in i m sorry patient treatment is provided. Education, research and development, regulation, and policymaking room all considered an additional uses that the patient record.

Practical considerations required the committee to emphasis on specific high-priority record offers rather than on all feasible functions that the record. The four significant categories of patient document uses considered by the committee were direct patient care, administration and management, reimbursement, and also research.


Translating customer Needs right into System Requirements

Proper system design method achieving a patient record system that correctly fits, interacts with, and communicates in the welcomed manner of every user community the mechanism supports. This type of design is important if automatic patient record systems room to be adopted by users. The committee defined the needs of patient document users in terms of system role and worries of implementation and also operation. System duty is what the system enables users come do and also what that does because that them. Implementation and also operation problems relate to the factors users think about in acquiring and installing a system. These factors are necessary regardless of the kind of the document (e.g., record or computer-based).

The particular features users seek in patience records and also record systems room described below in regards to the computer-based patient document (CPR). Many of these desired features are usual to two or more significant kinds of record users. Unique involves or demands of a user group are also identified. Box 2-3 presents an overview of user requirements.


BOX 2-3

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


In translate into the list of user requirements, the committee detailed two special considerations. First, user requirements can problem with each other—not just amongst groups (e.g., patients and also practitioners require confidentiality, yet claims payers seek accessibility to thorough clinical information), but likewise within a single user team (e.g., doctors want accessibility to details to be really fast, yet they may likewise want to be able to sort info according to complicated logical rules, i m sorry slows solution times). Come the level possible, the committee resolved such problems by using wise rules of priority. In number of cases, however, the conflicts remained nettlesome and are disputed in chapter 4 as certain challenges to future patient record development.

Second, in ~ a technological frontier, customers might have challenge expressing or also imagining a need. This situation may well happen with the computer-based patience record, which contains opportunities for functional characteristics that many users would not think come request. The pioneering designer have to not just ask, "What do people want?" yet also, "What would human being want if castle knew what could be done because that them?"


Patient record Functions

The traditional function of patience records has actually been to store details relevant to the treatment of a patient for succeeding retrieval. Patient record systems need to offer individuals at least two added functions. First, documents should have the ability to guide the procedure of clinical difficulty solving. Second, records should support clinicians through decision analysis, reminders, danger assessment, and also other "intelligent" attributes not easily accessible with record records.


Storage

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

ACCESS very first and foremost, individuals want come retrieve information conveniently when and also where they need it. Other attributes of a patience record mechanism are basically irrelevant to individuals if they cannot gain access to the system, to the documents in the system, or come the data in the records.

Access can be explained in terms of availability, convenience, reliability, 3 and ease the use. A patient record mechanism should permit authorized clinical customers convenient accessibility to any kind of record 24 hrs a day. This requirement means an adequate variety of conveniently situated terminals or work-stations, no device downtime, no shed records or data, and accessibility to the document by more than one user in ~ the exact same time. Nonclinical users typically require accessibility to patient record data in ~ least throughout standard functioning hours.

Different individuals need different levels and also kinds of info (see box 2-4). The ease with which users locate or retrieve necessary data facets depends mainly on the record format. Current paper record styles tend come segregate rather than combine information; come facilitate interaction of essential information, an combined format is necessary. Thus, records must contain a front-page difficulty list to permit users come locate preferred information. In addition, document systems should enable users to "flip through" or quickly scan records; a table of components or index would be helpful for this purpose.


BOX 2-4

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


Several other capabilities are needed for optimal access. Customers should have the ability to display info at various levels that detail. Moreover, the system should permit practically every data item to be supplied as a an essential for retrieval and should also permit users to accessibility subsets that data. All users, nevertheless of their level of computer expertise, should have the ability to enter many queries without the treatment of a programmer; thus, an English-like retrieval language must be part of the system.

Accessing information when required includes more than detect an available terminal; indigenous the user"s suggest of view, it means an enough (i.e., fast) system solution time. Individuals want to execute their work at the very least as rapid as they right now perform them with file records. Exceptionally rapid retrieval that information, measured in fractions of a second, is critical function for major users that the CPR. In addition, clinicians, who are accustomed to creating or dictating your entries to patient records, want a comparable an approach in the CPR system to include data come the record.

From the users" perspective, the difficulty involved in discovering to use a system likewise affects access. Thus, operation of patient record systems must require only minimal training.4 maintain for doctors in details should be short and also easy, preferably occurring "on line" and at your convenience. Plenty of physicians are unwilling to devote huge blocks of time to discovering a brand-new record system, also if ultimately it could make their job-related easier. In addition, built-in, displayable "help" documentation on device operation and also the data facets should be accessible to both clinical and also nonclinical users.

The inquiry of patient access to records is debated among practitioners. The is likely, however, that the trend toward enhancing patient access 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, practical status and also preferences amongst various treatments have actually been figured out as data that could be taped by patient to help practitioners in developing care plans.

Some practitioners encourage patients to audit their documents for accuracy and also completeness; lock may also use the record for patient education. Indeed, together patients come to be increasingly computer-literate, knowledge-seeking consumer of health treatment services, the CPR may role as crucial patient education tool by providing patients access to resources such together MEDLINE.

DATA high quality The id of data quality has actually several attributes: legibility, accuracy, completeness, and meaning. CPR systems eliminate the need for handwriting and also thus enhance legibility. Accuracy the CPRs have the right to be enhanced by data entrance screens and also logical rules that flag or block unreasonable entries for certain data fields. To the extent that CPRs reduce the require for one intermediary to enter data (i.e., for transcription), a potential source of errors (and cost) is removed. When errors execute occur, because that legal purposes the initial entry and the correction have to both be preserved (Waller, in this volume). Data accuracy likewise has ramifications for the security and reliability of CPR equipment insofar as the systems must ensure that data space not shed or unknowingly corrupted.5

The completeness that patient documents for subsequent users relies in part on agreement among users about uniform main point data elements. Without such uniformity, what one patient document user see as complete data might be considered incomplete through another. Data completeness implies that solution will accommodate the currently expected selection and complexity of clinical data and that they will permit brand-new data areas to be added and useless data fields to it is in identified.6

For patient records to accomplish user needs, patience problems and also the present status of patient problems should be clearly noted in the record. In addition, the is crucial that the health treatment provider"s rationale for clinical decisions be clearly documented. Absence of a videotaped rationale hinders the capability of succeeding users the the record to make proper judgments about patient care, high quality assurance, use review, reimbursement, and research.

For purposes of health services research, patient health status is the single most necessary data facet that is usually lacking from the patient records of today. Formal, interpretable details on health status is a precondition both to situation mix or risk aspect adjustment and also to evaluate of the outcomes the care. The research study community clearly wants health and wellness status information, accumulated in a standard format, to it is in a routine part of the record of the future. Together records need to also paper health risk determinants (e.g., smoking).

Technology assessment, clinical investigation, and health solutions research have been slowed by the absence of reliable, valid, standardized, consistently built up information ~ above the health status and also functional level of patient (Ellwood, 1988; Roper et al., 1988). Moreover, practitioners may benefit from routine accessibility of health and wellness status measures. Part evidence argues that without such measurements in regime clinical practice, physicians and also other health treatment professionals often overlook far-ranging impairments and also changes in duty among your patients (Nelson, 1990). In the past two decades, plenty of health solutions researchers have operated to develop, test, and refine wellness status actions with sound psychometric attributes (Katz, 1987; Lohr and also Ware, 1987; McDowell and Newell, 1987; Lohr, 1989). These type of methodological advancements could greatly increase the practical application the standardized health status data.

The committee recognized that the inquiry of whether and how soon health and wellness status evaluate will affect the quality of care remains to it is in addressed. To gain a much better understanding of the worth of health and wellness status measures, the committee sustained their widespread adoption as a ingredient of the patient record—but under problems that would permit testimonial of who they help and the how finest they deserve to be employed. The committee go not recognize an optimal collection of health status measure instruments, as this decision was not part of the charge. Rather, to broaden the basic of potential compare of situation mix, care, morbidity, and outcomes, the committee provided the potential worth of standardizing or otherwise enhancing the compatibility that those instruments now in common use.

It remains unclear just how outcome data have the right to be gathered and used unobtrusively, inexpensively, and conveniently enough that such activities will come to be widespread. Just adopting a computerized record style may not get over the obstacles that so far have impeded the diffusion of health status measurement right into routine clinical practice. Computerization may make the evaluation of such info easier yet may not impact its collection.

The completeness that patient records depends in component on the moment it takes come add brand-new information come the record, once that details is available. Data completeness can be magnified by linkages in between CPR systems and also ancillary solution (e.g., laboratory, radiology), which permit the move of outcomes from ancillary systems to the CPR in the hospital, physician"s office, or various other provider setup as soon as such results space available.

Maintaining the high quality of patience data likewise requires the the data have an interpretation for users. Effective retrieval and also use of details from patient documents depend top top consistency in naming or describing the same findings, clinical problems, procedures, drugs, and also other data within a solitary patient record, throughout many patient documents in a solitary record system, or in other systems the contain data relevant to the understanding and also treatment of patience problems. Communication amongst practitioners have the right to be aided through a typical clinical data dictionary and also a clinical coding device that space interchangeable any clinical data typical to various specialists or professions but details enough to define the detailed data unique to a job or specialty.

Health treatment researchers have a special need for document systems the provide an ext uniform results than are detailed by existing systems. Continuous description that clinical content becomes an ext important v the aggregation the data from many patient records—as in outcomes research, because that example. Standardized data dictionaries, coding schemes, and uniform data to adjust permit more complete, trusted analyses of treatment and condition patterns including multiple sites.7

SECURITY CPR systems have actually two defense requirements. First, as questioned in thing 1, patient and provider privacy must be protected. Second, data and also software should be safeguarded versus tampering and also unintentional destruction. This requirements demand both system and also data protection measures. System security refers to the actions taken to store computer-based info systems for sure from unauthorized access and other harm. Data security involves protection that data from inadvertently or knowingly disclosure to unauthorized persons and also from not authorised alteration.

Data security contains both data confidentiality and also data integrity. Data confidentiality is a ""requirement whose purpose is to save sensitive information from being disclosed come unauthorized recipients" (National study Council , 1991:52). Confidentiality requires appropriate activity by physicians, nurses, midwives, secretaries, medical technicians, paramedical staff, social workers, hospital managers, computer staff, and research investigators in health care facilities to safeguard the privacy of patience information. Confidentiality additionally requires that computer systems refuse access to not authorised individuals.

In its narrowest sense, data integrity refers to the consistency and also accuracy of data save on computer in computer-based systems. It is a "requirement intended to ensure that information and also programs are readjusted only in a specified and also authorized manner" (NRC, 1991:54). Data verity is that paramount prominence to the CPR, and also care have to be taken, specifically in distributed CPR systems (see thing 3), to ensure that records can be completely restored in the occasion of mechanism failures.

A wider definition of data truth could also be appropriately applied to patient data. Data are claimed to have integrity if lock comply v an a priori declared expectation that they have actually a defined set of attributes. This a priori set of qualities is distinct to the data, come the process operating on the data, and to the data holder. Such characteristics might incorporate timeliness (e.g., every data element is posted within five minutes that availability), completeness (e.g., a certain set of data facets must be component of the record), and accuracy (e.g., there space no assignment errors, every deal with has a zip code).

Data verity in future patient records can be magnified by including a data validity field that would flag data that might not be correct. Data validity would certainly be second parameter versus which integrity might be judged and thereby controlled. Informing succeeding users that an entry might be not correct would allow them to discount or overlook the information.

FLEXIBILITY individuals assign high priority to flexibility in records; they carry out not want to be compelled to use the record in a universally uniform or prescribed manner. Thus, future CPR systems need to permit customization that data entry formats, report formats, and also display formats—both for and, in some cases, by certain users. Patient document user needs are simply too many and too varied for any type of one mix of input, reporting, or screen options. Furthermore, research has presented that the ability to customize computer system interfaces follow to one"s preferences and also work habits increases user acceptance of computer system systems (Bikson et al., 1987).

Conventional styles should be designed and available as default modes, however the customers of the patient document of the future should find the document easy come mold to their individual, regional needs. Various formats for displaying details on the display or on file should it is in available. The document should additionally permit integration across disciplines and also professional specialties and administer different "views"8 of patience data for various users (see box 2-4).

Flexibility is also required to satisfy the varied reporting requirements of users, particularly physician specialties. Doctors require record information available both in easily accessible, traditional reporting styles (such together letters, insurance money forms, school and camp certificates, etc.) and also in formats they can quickly customize according to specialty and individual taste. Therefore, the CPR system should save on computer a user-friendly report generator for physicians and also others who wish come design devoted reports for their very own use.

CONNECTIVITY Connectivity denotes the potential that the record or record system to establish links or to communicate effectively with any kind of sort the provider or database the may improve the care of the patient. Three various interfaces are important in such interactions: the interface among records or record systems of various provider institutions, the interface between the record and also other repositories or potential repositories of details that might be beneficial in caring because that the patient, and the interface in between the record and a practitioner.

Linkages among the various clinical documents pertaining come a solitary patient are likewise important to users, who frequently want a longitudinal patient record—records from different times, providers, and sites of treatment that are linked to form a lifelong watch of a patient"s health care experiences. Linkages are likewise needed to carry patient data native one care setup to an additional (e.g., from medical professional office to hospital) to facilitate company coordination.

Linking the records of family members, or the records of people who got a details procedure in a specific facility, may prove valuable for some species of epidemiological analysis. The aggregation of patience data for massive analysis, however, calls for more facility kinds of linkages. Integration of pertinent subsets the data throughout institutional borders is especially important as researcher attempt to understand diseases and also episodes of condition independent the the details institution or health treatment professional through whom patients discover themselves in ~ a particular phase of your illness.

Patient document systems should likewise offer linkages to other databases and also other sources of information.9 desirable linkages encompass databases that contain clinical literature and bibliographic information, administrative information (e.g., coverage for a particular elective procedure for a offered insurance plan), medical practice guidelines, insurance allowance claims, and disease registries.

Connectivity renders several other demands top top the device as well. To make it an easy for the practitioner to communicate with the record, data entry should be nearly as basic as writing, and databases need to be arranged in such a method that any kind of terminal or microcomputer ~ above the system have the right to retrieve requested data. As provided earlier, communication among practitioners depends on usual data dictionaries and also clinical coding systems. To interface easily with a database or registry calls for a various sort of connectivity. Workstations have to be designed with telecommunications interfaces that permit the user come switch practically instantly between the info in the record and its relevant counterpart in the exterior knowledge base.

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

Any data gotten in into the mechanism should be obtainable for a selection of uses, removed the require for redundant data entry. (The require for manual extraction the data and also re-entry procedures significantly diminishes the value of a system.) The mechanism should be designed come ensure that data are obtainable to assistance patient care, business operations, and decision making. Thus, data should be regarded as an business resource, not home "owned" or controlled by the departments that take place to collect them or that room the main users that the data.

The CPR device should it is in a part of an combined patient care information system. If the mechanism is hospital based, that should communicate with equipment in the clinical laboratory, pharmacy, respiratory therapy, other ancillary services, referring doctor offices, and also other care settings (e.g., home, nursing home) so the data will not require manual transcription from one device to another. If the device is based in a physician"s office, it should communicate with the computer system systems of local clinical laboratories, pharmacies, hospitals, and also other physicians" offices.10

CPR systems have to facilitate the activity of data into, within, and also outside that the automated patience record. In particular, they should permit raw and also aggregated data to be moved to another electronic database for further evaluation and storage. For example, a hospital or individual physician should be able to extract selected information electronically from a patient care database to send come other internal or external (perhaps national) databases.11 In addition, the system should have no problem accepting data directly from digital monitoring devices and other patient care equipment.

Health care professionals perform countless routine governmental tasks in the food of giving services, and they seek methods to alleviate this bureaucratic burden so the they have the right to devote an ext time to direct patient care, research, and education. Patient record systems should provide the volume to generate routine documents based on record data automatically, to send insurance insurance claims electronically, and to report adverse reactions or occurrences of tracked diseases automatically.

Computer-based records should be draft to prevent the just replication of file record features and also behaviors that, top top reflection, have tiny or no worth to users. Instances of waste incorporate information the is routinely collected but never used; inflexible, redundant styles for record data that an outcome in duplicative details (e.g., obsolescent hand-operated medication files); and retrospective quality assurance that could be replaced with online top quality assurance. Together features and also behaviors include cost quite than quality to the document system.

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The committee walk not particularly investigate the nature or limit of such wasted effort in present-day records, yet members mutual the general impression the it abounds. In arising the CPR, time would be well invested in helpful research to identify and remove this "non-value-added" steps, features, and data elements, v the intent of creating a document that is leaner, less complex, and more streamlined than that that today. This procedure is most likely to require alters in regulations or laws, and also the committee urges the such alters be analyzed, recommended, and adopted (see thing 5).