The computer-based patient record : an essential technology for health care / Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine ; Richard S. Dick, Elaine B. Steen, and Don E. Detmer, editors.

Format:

Book

Author/Creator:

Institute of Medicine (U.S.). Committee on Improving the Patient Record.

Contributor:

Dick, Richard S.

Steen, Elaine B.

Detmer, Don E.

Language:

English

Subjects (All):

Medical records--Data processing.

Medical records.

Medical care.

Physical Description:

1 online resource (256 p.)

Edition:

Rev. ed.

Place of Publication:

Washington, D.C. : National Academy Press, 1997.

Language Note:

English

Summary:

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.

Contents:

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

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

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?

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

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

Confidentiality and Security

Health Data-Exchange Standards

SUMMARY

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

User Behavior, Education, and Training

Costs

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

REFERENCES.

Appendix: Maternal and Child Health Care and Computer-Based Patient Records

5 Improving Patient Records: Conclusions and Recommendations

CONCLUSIONS

Data and Security Standards

Data Standards

Security Standards

Networking Support

Cost-Benefit Analysis

Quality Assurance

Structure and Format of the Patient Record

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

Index.

Notes:

Bibliographic Level Mode of Issuance: Monograph

Includes bibliographical references and index.

ISBN:

9786610210862

9780309175340

0309175348

9781280210860

1280210869

9780309578851

030957885X

9780585021096

0585021090

OCLC:

42328818