Question

How technology is used in recording and reporting?

Answer 1

In recent years, computerization of patient records has increased at a moderate rate and this trend is likely to continue, particularly as technology improves and becomes more affordable and as the demand for health care information increases. If future patient records are merely automated versions of most current records, however, an opportunity to improve a fundamental resource for health care will have been lost. For example, in the patient record of the future, the committee seeks the ability to access quickly a list of current problems, a trail of clinical logic, the patient's health status, and the most recent information about various treatment options for the patient's condition. Easy access to and sound organization of data elements can be provided by automation of patient records, but the availability of the data elements depends on whether practitioners collect and record such data in the first place. Further, access to bibliographic and knowledge databases will require new functions not provided by traditional patient records.

Thus, the automation of patient record retrieval, maintenance, and use is necessary, but not sufficient, for record improvement. Given existing and emerging computer technologies and the evolving nature of health care, the committee believes that the patient record can, must, and will develop to meet the expanding needs of the health care field. This chapter identifies the attributes of future patient records that are required to meet these needs, discussing several of them in detail to highlight the scope and complexity of the issues to be addressed.

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