Table Of ContentComputers 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.
