name a computerised record keeping system that provides the user efficient and reliable methods of data retrieval
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1 Introduction
The patient record is the principal repository for information concerning a patient's health care. It affects, in some way, virtually everyone associated with providing, receiving, or reimbursing health care services. Despite the many technological advances in health care over the past few decades, the typical patient record of today is remarkably similar to the patient record of 50 years ago. This failure of patient records to evolve is now creating additional stress within the already burdened U.S. health care system as the information needs of practitioners,1 patients, administrators, third-party payers, researchers, and policymakers often go unmet. As described by Ellwood (1988:1550),
The intricate machinery of our health care system can no longer grasp the threads of experience… Too often, payers, physicians, and health care executives do not share common insights into the life of the patient… The health care system has become an organism guided by misguided choices; it is unstable, confused, and desperately in need of a central nervous system that can help it cope with the complexities of modern medicine.
Patient record improvement could make major contributions to improving the health care system of this nation. A 1991 General Accounting Office (GAO) report on automated medical records identified three major ways in which improved patient records could benefit health care (GAO, 1991). First, automated patient records can improve health care delivery by providing medical personnel with better data access, faster data retrieval, higher quality data, and more versatility in data display. Automated patient records can also support decision making and quality assurance activities and provide clinical reminders to assist in patient care. Second, automated patient records can enhance outcomes research programs by electronically capturing clinical information for evaluation. Third, automated patient records can increase hospital efficiency by reducing costs and improving staff productivity.
Several sources support these conclusions. The GAO reported that an automated medical record system reduced hospital costs by $600 per patient in a Department of Veterans Affairs hospital because of shorter hospital stays (GAO, 1991). Reductions in the length of inpatient stays were also found in other studies of computerized medical records and medical record summaries (Rogers and Haring, 1979). Other investigators found enhanced care and improved outcome of care for clinic patients (Rogers et al., 1982) and a reduction in medication errors (Garrett et al., 1986).
The first step toward patient record improvement is a close examination of the users of the patient record, the technologies available to create and maintain it, and the barriers to enhancing it. To that end, the Institute of Medicine (IOM) of the National Academy of Sciences undertook a study to recommend improvements to patient records in response to expanding functional requirements and technological advances. 2 This report is the product of the multidisciplinary panel's 18-month study of how patient records can be improved to meet the many and varied demands for patient information and to enhance the quality of patient care and the effectiveness and efficiency of health care delivery.
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