Aspects of the Computer-based Patient Record PDF
Preview Aspects of the Computer-based Patient Record
Computers in Health Care Kathryn 1. Hannah Marion J. Ball SeriesEditors Computers inHealth Care Series Editors: Kathryn J.Hannah Marion J.Ball NursingInformatics WhereCaringandTechnologyMeet M.J.Ball,KJ.Hannah, U.GerdinJelger, andH.Peterson HealthcareInformationManagementSystems APracticalGuide MJ.Ball,J.V.Douglas, R.I.O'Desky,andJ.W.Albright KnowledgeCoupling NewPremises andNewTools/orMedical CareandEducation LawrenceL.Weed DentalInformatics IntegratingTechnologyintotheDentalEnvironment LouisM.Abbey andJohnZimmerman Aspects oftheComputer-basedPatientRecord MarionJ.BallandMorrisF.Collen Marion J. Ball Morris F. Collen Editors Aspects of the Computer-based Patient Record With 18Illustrations Springer Science+Business Media, LLC MarionJ.Ball,Ed.D. Morris F.Collen AssociateVicePresident DirectorEmeritus InformationResources KaiserPermanenteMedical CareProgram UniversityofMarylandatBaltimore 3451PiedmontAve. 610 WestLombardSt. Oakland,CA946I1,USA Baltimore,MD21201,USA Coverillustration:TheilluminationonthecoverisfromamedievalmanuscriptfoundintheNational Library ofMedicinecollection. Thismanuscript, byHunain IbnIshaq,ElAbadiis,isfromthe 13th century. ThisistheoldestbookintheNationalLibraryofMedicine'scollection. LibraryofCongressCataloging-in-PublicationData Aspects ofthecomputer-basedpatientrecord/MarionJ.Ball,Morris F.Collen,editors. p. em."(Computersinhealthcare) Includesbibliographicalreferencesandindex. ISBN 978-1-4757-3875-9 ISBN 978-1-4757-3873-5 (eBook) DOI 10.1007/978-1-4757-3873-5 I. Medicalrecords-Dataprocessing. I.Ball,MarionJ. II.Collen,MorrisF.(MorrisFrank),1913- . II.Series: Computersinhealthcare(NewYork,N.Y.) R864.A871992 65I.5'0426I'0285"dc20 91-33021 Printedonacid-freepaper. ©1992SpringerScience+BusinessMediaNewYork OriginallypublishedbySpringer-VerlagNewYorkInc.in1992. Softcoverreprintofthehardcover Istedition1992 Allrightsreserved.Thisworkmaynotbetranslatedorcopied inwholeorinpartwithout thewritten permissionofthepublisher(SpringerScience-BusinessMedia,LLC),except forbriefexcerptsin connectionwithreviewsorscholarlyanalysis.Useinconnection with any form of information storage andretrieval electronicadaptation,computersoftware, or bysimilarordissimilar methodology nowknownorhereafterdeveloped isforbidden. Theuse ofgeneraldescriptive names, trade names,trademarks,etc.,inthis publication,even ifthe former arenotespeciallyidentified,isnottobetakenasasignthatsuchnames,asunderstoodbythe TradeMarksandMerchandiseMarksAct,mayaccordinglybeusedfreelybyanyone. Whiletheadviceandinformationinthisbookisbelievedtobetrueandaccurateatthedateofgoingto press,neither theauthorsnortheeditorsnorthepublishercanacceptany legalresponsibilityforany errors oromissionsthat may be made. The publisher makesno warranty,expressor implied,with respecttothematerialcontainedherein. ProductionmanagedbyChristinR.Ciresi;ManufacturingsupervisedbyJacquiAshri. TypesetbyPrincetonEditorialAssociates,Princeton,NJ. QR7fi~412 1 ThebookisdedicatedtoJudithVetterDouglasingratefulrecognition ofherdiligenceanddevotiontomakingtheseriesentitled"Computers inHealthCare"thesuccessitistoday. Herdedicationtoworkingwith thecontributingauthorshasearnedhertherespectofthe international informaticsfield. ItisindividualssuchasJudithVetterDouglaswho makeitpossibletocontinuallyproducesuchhighqualitymanuscripts. ItiswithgratefulappreciationthatIwishtoacknowledgethecontinu ing invaluablesupportthat Ireceivefrom Judith. MarionJ.Ball, Ed.D. Foreword DonE.Detmer Healthcareisexperiencinganinformationexplosionintheformofknowledgeand data.Medicalknowledgeisincreasingvirtuallyonadailybasis.Thequestionsthat weareaskingabouttheappropriateness andeffectiveness ofclinicaltreatments willprovideevenmoreinformation for practitioners to considerin providing patientcare.Wehavemoredataandmorecomplexdatatotrackforpatientsover thecourseoftheirlives. Atthesametimeasthequantityandcomplexityofpatientdataareincreasing, thereisgreaterdemandfordatatosupportactivitiesotherthandirectpatientcare. Healthservicesresearchers,managersofproviderinstitutions,thirdparty payers, andothersseekaccesstopatientcaretoevaluate, manage, andreimburse health careservices.Wedonot,however,haveameansofmanagingallofthisknowledge andthesedata,andthislackofinformationmanagementcapabilityisaddingstress tothealreadyburdenedU.S.healthcaresystem. InApril1991, theInstitute ofMedicine (10M) of theNational Academy of Sciencescompletedan18-monthstudyonimprovingpatientrecordsinresponse to the need for better information management and increasing technological advances. Thestudywasconductedbyamultidisciplinary committeeofexperts andwasfunded byadiversesetofpublicandprivatesectororganizations. The studycommitteewaschargedtodothefollowing: • Examinethecurrentstateofmedicalrecordsystems • Identifyimpedimentstothedevelopmentanduseofimprovedrecordsystems • Identifywaystoovercomeimpedimentstoimprovedmedicalrecords • Developaresearchagendatoadvancemedicalrecordsystems • Recommendpoliciesorotherstrategiestoachievetheseimprovements Theconclusions andrecommendations of thisstudyaredescribed inTheCom puter-BasedPatientRecord:AnEssentialTechnologyforHealth Care (National AcademyPress1991). Asameansofaccomplishingitsworkandachievingbroaderrepresentationin thestudyprocess,thecommitteeestablishedsubcommitteestoexplorethreemajor dimensions of patientrecordimprovement. Donald Berwick, M.D., andCarmi viii Foreword Margolis, M.D.,chairedtheUsers and Uses Subcommittee,which wascharged withidentifying theusersofpatientrecords, theusesofpatientrecords, andthe functional characteristicsofrecords thatwouldmeetuserneeds.TheTechnology SubcommitteewaschairedbyMorrisCollen,M.D.,andMarionJ.Ball,Ed.D.,the editors ofthisvolume.Theirtaskwastoexaminethecurrentstateoftechnology availabletosupportpatientrecordsandtoidentifytheareaswherepatientrecord technologycouldnotyetmeettheneedsofusers.Thethirdsubcommittee,Strategy andImplementation,waschairedbyEdwardShortliffe,M.D.,andPaulTang,M.D. Thissubcommitteewaschargedwithdefiningastrategytoovercomethetechnical, logistical, sociopolitical, andfinancial impediments to timelyphasedimprove mentsinthepatientrecord. Thedetailedworkofthethreesubcommittees contributedsignificantly tothe committee'sdeliberations,asdidseveralbackgroundpapersthatwerepreparedon specificissuesforthecommittee.Oneofthechallengesfacedbythecommitteein preparing its reportwastoprovidea thorough yetconcisedescription of what patientrecordsshouldbeandwhycomputer-basedpatientrecordsareessentialto healthcare. Asa result,all of thedetailed papersthatwereconsidered by the committeewerenotincludedinitsfmalreport.Thisvolumecomplementsthestudy committee'sreportbypresenting thesubcommitteereports,aswellasdiscussion papersandbackgroundpapers. Thevolume thusprovides avaluable serviceby enablingustosharethosecontributionswithabroaderaudience. Iofferabriefdiscussionofthestudycommittee'srecommendations belowto providea framework within whichthe contents of this volume can be better understood. For a moredetailed explanation of the recommendations and the rationaleunderlying therecommendations,Ireferyoutothecommittee'sreport. The firstandprimary recommendation of thecommittee is thathealth care practitioners shouldadopt the computer-basedpatientrecord(CPR) as thestan dardfor medical and all other recordsrelated topatientcare.Thefuture patient recordenvisionedbythe10Mcommitteeisnotsimplyadigitized versionofthe currentpaperrecord;rather,itprovidesbroaderfunctions topractitioners,isused actively bypractitioners inthedelivery ofcare,andserves asaresource inthe evaluationandmanagementofpatientcare. The committee developed a veryspecific definition of whata CPR is and identified basic attributes of CPRsand CPR systems. CPRs shouldcontaina problem list,health statusandfunctional level,andclinicianrationaleforpatient caredecisions.Theyshouldbe abletobe linkedwithotherclinicalrecordsto providealongitudinalpatientrecord.CPRsystemsmustprotectpatientconfiden tiality.Theymustalsoprovideconvenientaccesstoauthorizedusersatalltimes, supportdirectdataentrybypractitioners,andallowcustom-tailoredviewsofthe data. CPR systems shouldbe able to be linkedto knowledge, literature, and bibliographic databases. Theymustbe flexible and expandable to support the evolving needsofusers.SuchCPRsandCPRsystems willassisttheprocessof clinicalproblem solvingandenablepractitionersandinstitutions toevaluateand managethequalityandcostsofcare. ThecommitteeconcludedthattheCPRisanessentialtechnologyforhealthcare Foreword ix forthreekeyreasons.First,theusesanddemandsofpatientdataareincreasing. Second,theincreasingcomplexity oftreatment,thegrowing numbers ofelderly patientswithchronicillnesses,andacontinuallymobilepopulationaregenerating moredatatobetrackedandgreaterdifficulty intracking them.Third,achieving thegoalsofimprovingthequalityandmanagingthecostsofhealthcarerequires improvedinformationmanagementcapabilities. ThecommitteealsoconcludedthatwidespreadimplementationofCPRscanbe achievedwithinarelativelyshorttimeframe(i.e.,10years)ifadequateresources andcoordinationaredevotedtotheeffort.Thecommitteebasedthisconclusionon theincreasingprevalenceofcomputersineverydaylifeandtheadvancesachieved todateincomputerandnetworking technologies. Thus,thecommittee's second recommendationisthatthepublicandprivatesectorsshouldjoininestablishing aninstitutetopromoteandfacilitatethedevelopmentandimplementationofCPRs. Suchaninstitute wouldbeinvolved inarangeofactivities including standards setting,demonstrationprojects,andeducationalprogramsonCPRs.Thecommittee proposedanorganizationalstructureforsuchaninstituteinitsreport,butempha sizedthatthemeansusedtoachievewidespreadimplementationofCPRsareless importantthanachievingthatend. Thecommittee's fourremainingrecommendationsidentifywaystoovercome specificbarrierstoCPR developmentandimplementation.Thecommitteerecog nizedthat,althoughagreatdealofprogresshasbeenmadeincomputertechnology, moreworkisneededforCPRstomeetthefunctionalrequirementsofusers.Thus, the committee recommended that both the publicand privatesectors expand supportforCPRresearchanddevelopment,andthecommitteeprovidedanagenda toguidethatresearch.Thecommitteeemphasizedtheneedforandimportanceof both dataandsecurity standards in itsrecommendation thatthe CPRinstitute shouldpromulgatesuchstandards. Legalissuessurrounding CPRs needattention. Many statesdonotrecognize computer-basedrecordsasalegitimatemeansofstoringpatientdata.Thereisno consistency among state lawson patientrecordform, accessto records, and protection ofpatientrecords. Thus,thecommittee recommended thattheCPR institute conductareviewofstateandfederallawsandregulationsandpropose modellegislationandregulationstofacilitateimplementationoftheCPR.Sucha reviewshouldincludeanexaminationofunnecessaryregulations thataddwaste andredundancytopatientrecordssothatfuturerecordscanbestreamlined. Obviously,therearecostsassociatedwithdeveloping,acquiring,andoperating CPRsystems.Thecommitteebelievedthatthosecostsshouldbesharedbythose who benefitfrom the CPR andrecommended thatsuchcostsbefactoredinto reimbursementlevelsorpaymentschedulesofbothpublicandprivatesectorthird partypayers.UsersofsecondarydatabasescreatedfromCPRsshouldalsosupport thecostsofcreatingsuchdatabases. Success in CPRimplementation requires thatusers haveadequate computer skillsandthattherebemoreindividuals withtraining inmedical informatics to supportthedevelopmentofCPRs.The10Mcommitteerecommendedthathealth careprofessional schools andorganizations enhance theireducational programs x Foreword forstudentsandpractitioners. Thiseducational effortshouldaddress theuseof computers. CPRs. andCPRsystemsforpatientcare,education,andresearch. It isinteresting to notethatwhenthecommittee beganitsdeliberations, we identified twopossibleoutcomes thatmightresultfrom ourstudy. First,itwas possible that little wouldresult from our effortsince the conceptof linking computersandpatientrecordswasnotanewoneandprogressinthatareahadbeen slow. Second, it waspossible that theconditions wererightfor us to makea contributiontowardadvancingcomputer-basedpatientrecordsbymakingastrong caseforthevalueofsuchrecordsandidentifyingthepotentialtoachievethem.All ofthecommitteecompletedtheprojectwithagreatdealofoptimismandenthusi asmforafuturevisionofcomputer-basedpatientrecords-avisionthatwestrongly believecanbecomeareality. Thecommitteeconcludeditsworkwiththehopethatitsreportwouldgenerate increasedcommitmenttoandresourcesforpatientrecorddevelopment.Ontheday thatthereportwasreleased,mytestimonybeforetheHealthSubcommitteeofthe WaysandMeansCommitteeintheU.S.HouseofRepresentativesonbehalfofthe 10Mstudycommitteereceivedaveryreceptivehearing.Congressionalinterestin this issue is evidentin the form of H.R. 1565 (102dCongress, first session, 1991}-whichwouldprovideastrongimpetustoachievingourCPRagenda. Within aweekofthereportrelease, wealsohadtheopportunity tosharethe resultsofthestudydirectly withtheAmerican MedicalAssociation Council on ScientificAffairs,theAmericanMedicalRecordAssociation,andtheNewEngland HealthcareAssembly.Additionalbriefingsandpresentationshavebeengiventoa varietyofgroupssincethen. At the time of this writing, it is impossible to judge how successful the committeeanditssubcommitteeswillprovetobeinadvancingCPRdevelopment and implementation and,in so doing,influencing theshapeof the health care system of tomorrow.Wecertainly weresuccessful inlearning from oneanother andweshareacommonsenseofwhatthefuturecanhold. Iamconfidentthatyouwillbothenjoyandbenefitfrom thevariouscontribu tionsinthisvolume. The10Mpatientrecordstudybroughttogetherpeoplewith thegreatestexperienceandinterestinthissubject;morethan200individualsfrom acrossthenationwereinvolvedwiththiseffort.Theprojectprovedtobeconsis tentlychallenging,illuminating,andentertaining. A final word of appreciation is offered to all of the committee members, subcommitteemembers,andsubcommitteeadvisorswhocontributedtothestudy. Aschairofthestudycommittee,Iampersonallygratefultotheindividualswhose workappearsinthisvolumefortheircontributionsnotonlytothestudybutalso tomyownunderstandingoftheissuessurroundingcomputer-basedpatientrecords. Iwouldalsoliketoacknowledge thestudystaff,ElaineSteenandRichardDick, for their continuing expertiseand efforts to bring the reportto a timely and successfulconclusion.CliffGoodmandeservesmentionforhelpingstartthestudy, asdoDickRettig,QuetaBond,andSamThier.Completionofthestudyalsoisa resultoftheeffortsofKathyLohrandKarlYordy.
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