Essential Technologies for Computer-based Patient Records: A Summary
The purpose of this summary is to convey an overall view of the technologies that are relevant to or are exhibited in today’s computer-based patient record (CPR) systems and also to highlight those technologies that will be required to build the state-of-the-art CPR systems of the near future. The needs of users of systems are the most important consideration in the design and development of any computer-based system. It is important that the designers and implementers of systems understand not only the users, but also how they will use the system and what demands they will place on the system to meet their evolving needs. Some of these users and uses have specific technologic implications of which designers of CPR systems need to be cognizant. In general, current CPR systems do not address the information needs of many of these users.
We hope that designers and developers of CPR systems and, in particular, CPR vendors will make use of the information contained in this book as they commence their design of future CPR systems. The recommendations section, especially, should be considered by CPR designers and developers. It is intended that CPR designers will use this document as a resource for gaining insight into features that are most needed and desired by the health care community. Furthermore, we hope that this document will assist designers of CPR systems to anticipate the scope of future CPR systems, and that appropriate plans will be made early in the design process to accommodate the vast array of data and system linkages required to support the extensive requirements of all of the users of the CPR. The major design challenge will be the task of integration, that is, of building CPR systems using existing modules, subsystems, and components that address portions of, or individual applications among, the multitude of capabilities that need to be included in future CPR systems.
The following themes have emerged from this study. There is no single comprehensive CPR system available today that might serve as a model for emulation for future CPR systems as defined herein. CPR systems are, or should be, the heart of the entire health care information system, since all other peripheral systems (e.g., laboratory, pharmacy, or billing) feed data into or rely on data retrieved from the CPR. Today’s CPR has rarely been, but should be, a longitudinal (lifelong) record, that is, it should have all patient data for all time the patient is cared for within a health care program. As a lifelong record, the CPR must be transferable and even transportable (portable data carrier, laser card, smart card, etc.) so that crucial data concerning the patient is readily available regardless of where the patient seeks care. Database management systems (DBMS) and database technologies have evolved to the point where they are essential for storage and integration of the CPR. The CPR is so complex that no single database can accommodate all of its data, and an integrating DBMS is essential. A distributed database environment (with its attendant advantages and disadvantages) with broadband, high speed communications networks is implied in future CPR systems. Terminals and workstations will be the primary tools used by health care professionals to interact with the CPR systems. At a minimum, to satisfy the clinical requirements of health care professionals, the terminals must support text and graphics and the workstations must support high quality images, mouse-type data selections, windowing, graphics, and sound, while providing subsecond response times to most queries. Data acquisition is perhaps the most crucial element to be addressed in the future CPR systems. Clearly, the systems must be so easy to use and unobtrusive that health care professionals can enter data in an amount of time comparable to or less than the time used for paper-based patient records. Productivity gains should be sought, but CPR systems of the future should not require more time than the health care professional is now accustomed to use in the course of providing care. Voice input or voice recognition is an important element of future CPR systems. Display technologies will also be important to the success of future CPR systems. Flexible displays tailored to the specific needs of clinical care users are likely to be crucial. The patient record is a complex mix of information containing high quality images from radiology, as well as from other departments that use images as diagnostic tool for patient care. These high quality images present some significant challenges to the CPR system of the future, but technologies will soon be in place to make all types of images from the CPR available throughout a health care facility.
Both data and system communication standards for transmitting complete or a partial patient records are of prime importance to the realization of the CPR. Significant efforts are now underway to support record format standards development, but much more needs to be accomplished in this area before the whole of the CPR can be shared within and across institutions. A tougher problem is the standardization of vocabularies (data terms and items) that appear in many portions of the patient record. This is a content rather than a format issue that has only recently begun to be addressed in any substantive way. Vocabulary control in the CPR is an issue of immense importance to patient care, and it will require great efforts on the part of many organizations over a period of years before adequate uniformity is finally realized in the CPR. The universal use of communication standards, such as Fiber Distributed Data Interchange (FDDI-II) and Integrated Services Digital Network (ISDN) will make it possible to transmit the CPR or selected portions of it across fiber optic and other high speed, high bandwidth networks. The CPR, and especially high definition images from the CPR, will be among the first applications to test these new communications technologies that are now emerging.
Among the highest priorities for growth in the 1990s is the further development of data protection technology to ensure fully the privacy and confidentiality of patient data contained in the CPR. There are societal and legal concerns related to these issues that should be resolved satisfactorily before the CPR can be more broadly realized. Much of the technology to assure the CPR security and integrity exists presently, but generally these technologies have not been adequately deployed or embedded in present CPR systems. CPR systems require a two-way linkage with other relevant primary care CPR databases. CPR systems also need to provide realtime linkages to clinical research databases, medical knowledge bases, and bibliographic databases to support care providers with timely, relevant, patient-specific information that facilitates more scientifically based, clinical decision making. In the other direction, the CPR must be capable of being used to create secondary research databases from which experiential knowledge (medical knowledge bases) can be derived.
There are no monumental or breakthrough technologies required to realize a CPR in the 1990s. Instead, what appears to be needed are more concerted efforts to focus existing and emerging technologies on building more effective and more clinically acceptable CPR systems. Examples of model centers—sites that have excelled at demonstrating various facets of the CPR—need to be established, and their progress highlighted as soon as possible. Similarly, demonstrations of advances in health care made possible by the CPR should be initiated promptly to accelerate the realization of the optimal CPR.
KeywordsHealth Care Professional Control Vocabulary Database Management System Asynchronous Transfer Mode Bibliographic Database
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