Computer-based patient records: a building block for health care reform.

While much of the country's attention is focused on the complexities of the health care reform debate, a basic concept is universally agreed upon: health care desperately needs improved information management capabilities. This concept is by no means a new one. In 1988, Paul Ellwood identified the health care system's need for a "central nervous system" to cope with the complexities of modem medicine.[1] In 1991, the Institute of Medicine (IOM) Committee on Improving the Patient Record released its report, outlining the need for a new generation of computer-based patient records (CPRs) to improve the care of individual patients and populations and articulating a vision of how CPRs could advance information management in health care.[2] This vision was adopted by the Computer-based Patient Record Institute (CPRI) in 1992 as the basis for its mission. And earlier this year, the federal government's Work Group on Computerization of Patient Records reinforced and refined the vision for CPRs in its report to the Secretary of Health and Human Services.[3]

Patient records constitute an essential building block for health care's information management capabilities. Unfortunately, patient records vary widely in form and availability, offer varying degrees of quality, and have not yet reached their full potential. Although genuine progress is being made, most patient records do not meet the current information needs of health care professionals. In this era of health care reform and in this information age, the inadequacies of current patient records (both paper and electronic) are all the more pronounced, as even greater information management demands loom on the horizon and better technologies are within our grasp.

CPR Vision

Three basic elements constitute the vision for CPRs. First, patient records will do a better job in their traditional role of keeping track of patient care events. They must meet the functional requirements of ease of operation; data accessibility, accuracy, and legibility; and protection of patient confidentiality. CPRs will go beyond current record-keeping capabilities. They will:

* Support the creation of a longitudinal

view of a patient's health

history.

* Offer greater flexibility in the

retrieval and display of patient

data.

* Capture data elements essential to

understanding the clinical thought

process behind patient care decisions

and to assessing the effectiveness

of treatments. Second, CPR systems will offer expanded functions that actively support clinicians in the care process and lessen the amount of time required for nonclinical tasks. Clinical alerts and reminders; decision support tools; video and graphic capabilities; and links to the medical literature, clinical practice guidelines, and research databases will all be accessible through the CPR. Routine forms, such as for school or insurance examinations, or patient instructions could be generated with a few keystrokes; billing information could be automatically sent from the CPR to the financial information system and forwarded electronically to third-party payers.

Third, patient record systems will support the information needs of the full range of legitimate users (including physicians, nurses, and other caregivers; patients; administrators; third-party payers; and researchers) and will become the core of health information systems both within and beyond health care organizations (e.g., regional health databases or information systems). If patient records and record systems cannot meet the needs of all users in terms of content and function through direct access or linkages to other information systems, we will continue to experience expensive proliferation of redundant information systems and wasteful duplication of data gathering and entry. Connectivity, data format, and data content standards must be met for systems to meet the needs of all users. Moreover, users must understand that the patient record is a resource for improving the effectiveness and efficiency of clinical processes and procedures, that complete and accurate data offers benefits well beyond the individual patient, and that information management (including record-keeping) is a critical component of the health care delivery process.

CPR Requirements

The IOM Committee on Improving the Patient Record identified 12 basic requirements for future patient records. According to the committee, CPRs must:

* Contain a problem list with the

status of each problem.

* Encourage health status and functional

level measurement to promote

outcomes assessment.

* Document clinical rationale.

* Link to other clinical records over

time.

* Protect confidentiality comprehensively.

* Provide timely accessibility to

authorized individuals.

* Allow selective retrieval and formatting

of data elements.

* Link to local and remote knowledge,

literature, databases, and

systems to aid decision making.

* Assist and guide clinical problem

solving.

* Support data collection and storage

with a defined vocabulary.

* Help manage quality and cost of

care.

* Be flexible and expandable to meet

needs over time. These 12 requirements provide a conceptual framework for future patient records and a baseline against which users can evaluate their current systems and judge future systems. This framework must be translated into specific system functions by developers in conjunction with users. Patient record systems are likely to offer these functions in a variety of ways to meet the different needs of practitioners in various settings, and some systems will likely offer functions in addition to these 12 minimum requirements. This framework should be viewed as dynamic. As the needs of users and technological capabilities continue to develop, the concept of patient records will continue to evolve.

CPR Role

What role will the CPR play in health care? Properly designed and used CPRs have significant potential to enhance quality of care. CPRs will offer practitioners reliable access to the full range of patient information, knowledge sources, and analytical tools at the point of care. Certainly, this represents an improvement over paper records that in some institutions are reported to be missing 30 percent of the time.[4,5] The data contained in CPRs will more easily be aggregated for clinical and health services research databases, thus facilitating the advancement of medical knowledge. Moreover, CPRs will support the diffusion of new knowledge (including clinical practice guidelines) by providing direct links to health care professionals.

CPRs can also contribute to moderation of the costs of health care delivery. The availability of a patient record that includes all relevant data from all the settings in which the patient has received care can eliminate duplicate tests ordered because previous results are not available. By routinely bringing clinical practice guidelines to physicians, CPRs will reduce inappropriate services. Linkages between CPRs and other information systems will reduce administrative costs through elimination of redundant data entry, streamlining of paperwork, and automatic performance of certain tasks, such as generating automatic discharge summaries that can be refined by physicians or reporting required data to federal, state, and local health agencies.

CPRs also offer health care professionals and institutions a means by which they can increase their accountability to the patients and the communities they serve. By capturing outcomes data and linking to financial systems, CPRs will enable health care providers to document the quality and costs of their services and compare the value of their services to that of other practitioners and institutions through severity-adjusted aggregated databases. The availability of this information will enable patients to make more informed decisions in selecting physicians and health care institutions. Ultimately, high-value (i.e., higher quality, lower cost) providers should benefit from increased patient volumes.

CPR Progress

Although the application of computers to patient records has been under way for more than 30 years, health care lags behind other industries in the use of computers as a means of managing vast amounts of information. The complexity of health care delivery is a major factor that has slowed technological development of CPRs; early computers and software did not have the capacity or sophistication to support a comprehensive patient record system. Today, examples of automated patient records can be found in various stages of development in a variety of patient care settings, including health maintenance organizations, outpatient clinics, hospitals, and multihospital systems. In addition, clinical decision support systems that address the management of patients with infections, general medical diagnosis, drug-therapy decisions, and the management of chemotherapy for patients who are participating in formal clinical trials are available and in use. At the time of its study, the IOM committee concluded, on the basis of a review of existing automated record systems and emerging technology that no existing system met all of the requirements for CPRs and that, although most technological barriers to CPR development have been eliminated or are about to disappear, additional research and development are needed to advance CPRs, particularly in the areas of data acquisition, system security, data standards, and networking support.

Technology has not been the only limiting factor in the slow development of CPRs. A range of nontechnological barriers also must be addressed as part of any strategy for achieving CPRs. A basic impediment to CPR development is the lack of a clear-cut definition of what a CPR should be able to do, who its users are, and what their performance expectations are. Without such a definition, successful CPR design cannot be achieved. In addition, system purchasers and users lack awareness of CPR capabilities and do not have adequate information about the benefits and costs of CPRs to support acquisition decisions.

Until the creation of CPRI, there has been no infrastructure to support CPR development and diffusion. There was no framework for addressing the lack of standards for data transfer, the disincentives created by the high costs associated with CPR development and acquisition, the lack of experts trained in medical informatics, the need for training all CPR users to support the behavioral change that will accompany introduction of CPRs, the legal impediments created by inconsistency among states in laws related to patient records, the need for secure networks to transmit health care information, and concerns of the public about confidentiality. Until recently, there was no single leader or leading organization to advocate CPR needs and expedite CPR decisions. With CPRI, this void has been filled, and CPR development efforts should be accelerated as these infrastructure issues are addressed.

CPRs and Health Care Reform

Health care reform in the United States has finally reached front and center stage. The need for reform appears to be widely accepted. The debate on the mechanics of the reform is far from over, and the timing of reform implementation is impossible to predict. It is perfectly clear, however, that health care needs improved information management capabilities immediately. It is also clear that, whatever structure health care reform eventually takes, health care will need advanced information management capabilities to manage the quality and costs of services at individual, institutional, regional, state, and federal levels. While the reform debate rages, or ebbs and flows as the case may be, health care professionals and institutions can undertake their own reform by improving their information management skills and technology to transform how they perform their work.

CPRs cannot solve all of the challenges facing the U.S. health care system. They can and will, however, make an essential contribution as tools that enable us to measure value of services, improve health through the application of expert knowledge, moderate costs, and increase accountability. As CPRs enable us to accomplish these objectives, they will support our efforts to renew the social contract between the health care community and the public. Ultimately, such a renewal would be the biggest and most desirable reform of all.

References

[1.] Ellwood, P. "Shattuck Lecture--Outcomes Management: A Technology of Patient Experience." New England Journal of Medicine 318(23)1549-56, June 9, 1988. [2.] The Computer-Based Patient Record: An Essential Technology for Health Care. Dick, R. and Steen, E., Eds. Washington, D.C.: National Academy Press, 1991. [3.] Work Group on the Computerization of Patient Records. "Toward a National Health Information Infrastructure." Washington, D.C.: U.S. Government Printing Office, April 1993. [4.] General Accounting Office. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care. Washington, D.C.: U.S. Government Printing Office, 1990. [5.] Tufo, H., and Speidel, J. "Problems with Medical Records." Medical Care 9(6):509-17, Nov.-Dec. 1971.

Don e. Detmer, MD, is Vice President and Provost for Health Sciences, University of Virginia, Charlottesville. He was Chair of the Institute of Medicine Committee on Improving the Patient Record (1989-91).