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Patient records.

Richard Hamming, the inventor of error-correcting codes for computers, said, "If you don't work on important problems, it's not likely that you'll do important work." Echoing this idea, Don E. Detmer and Elaine B. Steen remind us in their recent article, "Patient Records in the Information Age" (Issues, Spring 1993), that the lack of usable electronic patient records is a very important problem for the U.S. health care system. The current increased level of interest in this problem is encouraging. We must remember, however, that medicine's central need for machine-readable patient records has been clearly acknowledged and given high priority in medical informatics research for 30 years. Why these years of effort by so many talented groups have not yielded computer-based patient record systems of the sort advocated in the 1991 Institute of Medicine report is not well understood. Lack of high-performance computing machines likely provides only part of the answer.

In any event, Detmer and Steen provide an excellent summary of the technological, social, and organizational barriers to a coordinated national patient data system and of the current range of efforts directed toward removing these barriers.

The National Library of Medicine (NLM) endorses and supports the computer-based patient record. NLM has programs (1) to reduce the difficulty of linking computer-based patient records to related machine-readable information in practice guidelines, recent scientific literature, expert systems, and so on; (2) to fund medical informatics training programs at a number of U.S. universities; and (3) to support, in collaboration with the National Science Foundation, the connection of health care facilities to the emerging high-speed national communications network. This third effort is part of the multiagency High Performance Computing and Communications (HPCC) program established in 1991 by the President's Office of Science and Technology Policy.

President Clinton's new technology initiative includes plans for increased investment in the HPCC program. In support of these plans, NLM has recently issued a Broad Agency Announcement for Biomedical Applications. Proposals are invited in several areas directly related to electronic patient records, including establishment of testbed networks to allow sharing of medical data and images among hospitals, clinics, doctors' offices, medical schools, medical libraries, and universities; software and technology for visualizing and analyzing diagnostic images, such as x-rays and CAT scans; integration of data from multiple computerized sources, including patient record systems; and data base, computing, and communications technologies for storing, accessing, and transmitting patient records while protecting data accuracy and privacy. This new initiative is cosponsored by the Agency for Health Care Policy and Research, the National Cancer Institute, and the Department of Defense Advanced Research Projects Agency. It thus provides some evidence of the federal coordination that Detmer and Steen look to as essential to realizing the goal of an effective national computer-based patient record system.

DONALD A. B. LINDBERG Director, National Library of Medicine Director, National Coordination Office, High Performance Computing and Communications Bethesda, Maryland

BETSY L. HUMPHREYS Deputy Associate Director Library Operations National Library of Medicine

Once again the powers that be propose a nationwide system of records to keep track of all of us. In "Patient Records in the Information Age," Don E. Detmer and Elaine B. Steen propose that "systems must track all events" and that "systems must connect within and beyond an institution," and make other statements implying a nationwide computer net to track all health care. This makes no sense. It is expensive, cumbersome, and likely to be ridden by political influences with little control of privacy.

There is a group that takes a different approach: The patient record belongs to the patient, who should have the right to control access to it and to know who uses it. It should contain the total medical record, be accessible at any location where health care is given, be capable of immediate updating, and be safe.

Working as a consultant, I have participated in tests at several locations in the Houston area of an optical card for this purpose. The optical card is a credit card with a special surface that can be punctured by a small laser beam. Some 1,500 pages of information, including x-rays and MRIs, can be placed on the card, which holds about 3 megabytes of information. With a reader-writer connected to a personal computer (no mainframe is needed), the data can be accessed, visit data recorded, and observations in plain text entered. The patient carries the card and submits it to the system when necessary. In an emergency, the data is on the person of the victim. The card can be backed up with another card, optical disks, or tape for aggregation of statistical data and replacement of lost cards.

In our trials, we find that 93 percent of patients carry the cards at all times and that loss is negligible. We have found no card that cannot be read despite rough treatment by patients. The cards are much cheaper than computer chip cards and carry more information. The reader-writers are expensive ($2,000) at the moment, but demand and competition will reduce the price.

Of greater importance, the card connects the practicing physician directly into the loop. With a simple personal computer and a reader-writer, the physician can be tied into the treatment, prevention, and billing systems. Software permits the use of any type of computerized record system.

Providing everyone in the country with a card at about $5 per card would be relatively inexpensive compared with mainframes and terminals. Several companies (mostly Japanese) are making reader-writers and cards, and the system is under test not only in the United States but in Europe and elsewhere. Although there are still bugs to be worked out, the system appears to offer major advantages to the delivery of health care.

J. H. U. BROWN Houston, Texas (The writer is a former director of the National Institute of General Medical Science at the National Institutes of Health.)

Don E. Detmer and Elaine B. Steen provide an excellent overview of the many benefits promised by a comprehensive, computer-based patient record (CPR) system. Consumers and providers can expect ready access to complete and accurate data, alerts, reminders, clinical decision support systems, and other aids to improve the quality of care. Institutional and organizational administrators will recognize the value of electronic data access in managing the cost and efficiency of services provided. Health services researchers, policymakers, and medical researchers will increase knowledge of and about medicine through analysis of detailed aggregated patient clinical data.

When describing how to make it happen, however, the authors fail to explain why the CPR isn't already a reality. The list of technical and nontechnical obstacles is complete and accurate, yet similar challenges have been repeatedly overcome across many different settings and industries. For example, the personal financial services sector has elegantly achieved facile user interfaces, security technology, networking capability, data standards, confidentiality, and service standards.

The fundamental reason for the lack of integrated CPR-based information systems in health care is the lack of integration in health care systems. Providers of care are fragmented into relatively small business units. Payors other than federal and state governments also operate as multiple small and dispersed purchasing units. The number of buyers and sellers is only a small part of the complexity that resists integrated information systems. The chief source of organizational fragmentation in health care delivery in the United States is the plethora of companies offering specialized administrative and financial services in the health care industry.

Proponents of health care reform identify the administrative cost savings of operational simplification through standard benefits, standard transactional data sets, and standard policies. Introduction of the CPR will help and be helped by this aspect of the reform. But the primary impetus for CPR adoption will be organizational rather than operational reform.

It is likely that the Clinton health reform proposals will have a major impact on advancing managed care. Managed care represents a comprehensive approach to delivering health care to a defined population, with accountability for the overall cost, clinical quality, and service quality. Whether a managed care organization is a single business unit or a composite of provider business units, a coordinating organizational structure exists to define and manage performance. The information needs of these coordinating management structures are the key to realization of the CPR.

This is because success in managed care depends on how well an organization establishes high-performance, integrated health care delivery systems. Sophisticated management data are required to monitor and continuously improve these systems and to provide the cost and quality reporting demanded by payors. The incentives for implementing and achieving integrated clinical information systems thus become consolidated within a single business organization.

The current lack of integrated delivery systems linking providers, facilities, payors, and administrators perpetuates the obstacles to the CPR. Even with well-intentioned cooperation among these groups, absence of integrated delivery systems will likely cause data in patient records to be incomplete and of low value. Unaligned or contrary business needs will continue to impede creation of a comprehensive clinical information system.

Managed-care systems are probably the only approach to effective integration of delivery systems. The Clinton health reform proposal could have a major impact on advancing managed care and, in turn, on establishing integrated delivery systems. The rapid adoption of the CPR technology will follow as a business solution to the management information needs of these organizations.

DAVID L. POTASH Vice President and Medical Director Managed Care Operations Aetna Health Plans Hartford, Connecticut

HOWARD BAILIT Senior Vice President Medical Policy, Research & Development Aetna Health Plans Hartford, Connecticut
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Title Annotation:response to Don E. Detmer and Elaine B. Steen, Issues, Spr 1993
Author:Lindberg, Donald A.B.; Humphreys, Betsy L.; Brown, J.H.U.; Potash, David L.; Bailit, Howard
Publication:Issues in Science and Technology
Date:Jun 22, 1993
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