Patient Records in the Information Age

Article excerpt

If you're out of town and need cash, an automatic teller machine can instantly determine if you have money in your account and let you withdraw what you need. If you apply for a loan, the lender can quickly get access to your credit history to help determine your reliability. If the Internal Revenue Service is reviewing your tax return and needs to know how much was withheld from your salary during the year, the information is readily available. But if you need emergency medical care and the physician needs information on your medical history, it is highly unlikely that it can be found and made available promptly. In fact, much of the information necessary to understand the workings of the U.S. health care system is not to be found no matter how long one is willing to wait. And without better access to medical data, the health care system wilt be hampered in its efforts to provide better care to individuals and to enhance the overall effectiveness of the entire system.

The information-management challenge experienced by health care professionals and institutions is growing daily. At least three factors contribute to this growth. First, health care practitioners must master and track an ever-increasing base of medical knowledge. MEDLINE, the computer data base of biomedical literature, grows by approximately 360,000 new articles per year. Second, patient records include more data as patients live longer, experience more chronic disease, undergo a greater variety of tests, and have more encounters with health care providers. Third, the demand for patient data is increasing. In addition to supporting the diagnostic and therapeutic work of clinicians, patient data are used to document patient risk factors, expectations, and satisfaction with treatment; to perform quality assurance, risk management, cost monitoring, and utilization review; to identify emerging public health problems; to track adverse reactions to pharmaceuticals; to document services provided for billing and legal purposes; and to assess the effectiveness of new technologies and procedures.

The users of patient data include not only physicians, nurses, and other health care practitioners but also virtually everyone associated with the health care delivery system. Patients themselves are increasingly likely to be interested in their records as they become more informed consumers of health care services. Administrators of health care institutions seek data to manage the quality and costs of services provided as well as to project staff, budget, and facility needs and identify opportunities for new programs. Insurance companies, other third party payers, and employers who pay for health benefits seek patient data to monitor the frequency, cost, and quality of health care services provided to their subscribers or employees. Health services researchers seek access to aggregated patient data to study patient outcomes, variations in practice patterns, or appropriateness of alternative treatments for a particular condition. Policymakers seek data to monitor the performance of health care institutions, to evaluate coverage decisions for federal and state insurance programs, and to evaluate the availability of health resources to meet current and future needs.

Patient records are a linchpin of information management in health care, but traditional medical records have not kept pace with the changes in health care and cannot satisfy many of the new demands placed on them. Despite the broad diffusion of computer technology, most patient records today exist only on paper and are often inaccessible, inaccurate, incomplete, illegible, disorganized, not secure, and not integrated into the various settings of care. Computerizing current paper records would help, but it would not meet all current and future user needs. Existing patient files do not have a standard form, do not integrate data from multiple care settings, and do not include all the types of data needed to enhance patient care and better manage the system. …