The computer-based patient record : an essential technology for health care

The computer-based patient record an essential technology for health care

Detalles Bibliográficos
Autor principal: Institute of Medicine (U.S.).
Autor Corporativo: Institute of Medicine (U.S.). Committee on Improving the Patient Record (-)
Otros Autores: Dick, Richard S. (-), Steen, Elaine B., Detmer, Don E.
Formato: Libro electrónico
Idioma:Inglés
Publicado: Washington, D.C. : National Academy Press 1997.
Edición:Rev. ed
Materias:
Medical records > Data processing.
Medical care.
Ver en Biblioteca Universitat Ramon Llull:https://discovery.url.edu/permalink/34CSUC_URL/1im36ta/alma991009820332606719
Tabla de Contenidos:
  • THE COMPUTER-BASED PATIENT RECORD
  • Copyright
  • Preface-Revised Edition
  • Preface-Original Edition
  • Acknowledgments-Revised Edition
  • Acknowledgements-Original Edition
  • Contents
  • Commentary
  • A Progress Report on Computer-Based Patient Records in the United States
  • THE CHANGING HEALTH CARE LANDSCAPE: REINFORCING THE NEED FOR CPRS
  • The Evolving Role of Primary Care
  • The Integrated Delivery System
  • Technological Advances
  • The Internet and the World Wide Web: Widespread Connectivity
  • World Wide Web Browsers: A Universal View on the Internet
  • The Intranet
  • Network-Centric Computing
  • THE CURRENT STATE OF CPRS
  • The CPR Market
  • Integrated View of Patient Data
  • Access to Knowledge Resources
  • Physician Order Entry and Clinician Data Entry
  • Integrated Communications Support
  • Clinical Decision Support
  • At the Fork
  • Recent Activity to Advance CPRs in the United States
  • Remaining Barriers or Challenges
  • Definition of the CPR
  • Meeting User Needs
  • Standards
  • Legal and Social Issues
  • Costs and Benefits
  • Leadership
  • CONCLUSION
  • ACKNOWLEDGMENTS
  • REFERENCES
  • Commentary
  • A Progress Report on Computer-Based Patient Records in Europe
  • THE CURRENT STATE OF CPRS IN EUROPE
  • CPR SYSTEMS IN PRIMARY CARE
  • Role of GPs
  • Training
  • Structure of Health Care
  • Population-Based Care
  • CPR SYSTEMS IN HOSPITALS
  • Platforms for CPRs
  • Integrated CPRs
  • CPR Data Entry
  • Natural Language Processing
  • Structured Data Entry
  • CPR SYSTEMS FOR SHARED CARE
  • CoCo
  • Diabcard
  • USE OF CPR DATA
  • Critiquing a Physician's Care
  • INTEGRATION OF PROTOCOLS WITH CPR SYSTEMS
  • Review of CPR Databases
  • ADDRESSING BARRIERS
  • Privacy and Confidentiality
  • Standardization
  • Electronic Health Care Record Architecture
  • Coding Systems for Drugs
  • Syntax for Health Care Data Interchange.
  • Exchange of Medical Images and Related Data
  • User Identification
  • CONCLUSION
  • REFERENCES
  • Summary
  • USER NEEDS AND SYSTEM REQUIREMENTS
  • COMPUTER-BASED PATIENT RECORD TECHNOLOGIES
  • NONTECHNOLOGICAL BARRIERS
  • RECOMMENDATIONS
  • 1 Introduction
  • THE STUDY
  • The Committee's Charge
  • Committee Activities
  • Definitions
  • REPORT ORGANIZATION
  • THE PATIENT RECORD
  • Strengths and Weaknesses of Paper Patient Records
  • Problems with Patient Record Content
  • Problems with Format
  • Problems with Access, Availability, and Retrieval
  • Problems with Linkages and Integration
  • Outpatient Records
  • INFORMATION MANAGEMENT CHALLENGES
  • An Information-Intensive Industry
  • An Information Explosion
  • Increasing Demand for Data
  • Maintaining Confidentiality
  • INFORMATION MANAGEMENT OPPORTUNITIES
  • BEYOND TECHNOLOGY
  • WHY NOW?
  • REFERENCES
  • 2 The Computer-Based Patient Record: Meeting Health Care Needs
  • DEFINING HEALTH CARE NEEDS
  • Patient Record Users
  • Patient Record Uses
  • TRANSLATING CUSTOMER NEEDS INTO SYSTEM REQUIREMENTS
  • Patient Record Functions
  • Storage
  • Guidance of Clinical Problem Solving
  • Practitioner Support
  • Implementation and Operation Issues
  • THE FUTURE PATIENT RECORD
  • REFERENCES
  • 3 Computer-Based Patient Record Technologies
  • TECHNOLOGICAL BUILDING BLOCKS FOR CPR SYSTEMS
  • Databases and Database Management Systems
  • Databases
  • Database Management Systems
  • Workstations
  • Data Acquisition and Data Retrieval
  • Data Acquisition
  • Data Retrieval
  • Text Processing
  • Image Processing and Storage
  • Data-Exchange and Vocabulary Standards
  • System Communications and Network Infrastructure
  • System Reliability and Security
  • Linkages to Secondary Databases
  • EXPERIENCE WITH CPR SYSTEMS
  • AN OVERVIEW OF CPR SYSTEMS
  • Physician Offices and Group Practice Settings
  • The Medical Record.
  • Health Maintenance Organizations
  • Computer-Stored Ambulatory Record Systems
  • Single Hospitals or Medical Centers
  • Theresa System
  • Health Evaluation Through Logical Processing
  • Beth Israel and Brigham and Women's Hospital System
  • Lockheed's Early Clinical Information System
  • Large Multihospital Systems
  • Department of Veterans Affairs
  • Department of Defense
  • International Developments
  • The Exmouth Project
  • Selected Emerging Developments
  • Chart Checker
  • Problem-Knowledge Coupler
  • Medical Logic Modules
  • CLINICIAN INTERACTION AND RESISTANCE
  • TECHNOLOGICAL BARRIERS
  • The Human Interface and System Performance
  • Text Processing
  • Confidentiality and Security
  • Health Data-Exchange Standards
  • SUMMARY
  • REFERENCES
  • Appendix: the Computer-based Patient Record System Vendor Survey
  • GENERAL OBSERVATIONS
  • SURVEY FINDINGS
  • 4 The Road to CPR Implementation
  • DEVELOPMENT AND DIFFUSION FACTORS
  • Barriers to Development
  • Patient Record Definition
  • Content and Format Standards
  • Costs and Risks
  • Barriers to Diffusion
  • Environment of the Health Care System
  • Leadership
  • User Behavior, Education, and Training
  • Costs
  • Legal and Social Issues
  • Network Needs
  • ELEMENTS OF AN IMPLEMENTATION STRATEGY
  • Change Agents and Stakeholders
  • Health Care Professionals and Professional Associations
  • Patients and Representatives of Patients
  • Provider Institutions
  • Third-party Payers
  • Federal Government
  • States
  • Universities and Professional Schools
  • Standard-setting Organizations
  • Vendors
  • Activities and Resources Critical to CPR Development
  • Organizational Structure
  • Federal Agency
  • Private Sector Sponsorship
  • Public-Private Commission or Consortium
  • Preferred Approach
  • Specific Steps for Change Agents
  • SUMMARY
  • REFERENCES.
  • Appendix: Maternal and Child Health Care and Computer-Based Patient Records
  • 5 Improving Patient Records: Conclusions and Recommendations
  • CONCLUSIONS
  • RECOMMENDATIONS
  • Data Acquisition
  • Data and Security Standards
  • Data Standards
  • Security Standards
  • Networking Support
  • Cost-Benefit Analysis
  • Quality Assurance
  • Structure and Format of the Patient Record
  • SUMMARY
  • Appendix A Subcommittees
  • USERS AND USES SUBCOMMITTEE MEMBERS
  • TECHNOLOGY SUBCOMMITTEE MEMBERS
  • STRATEGY AND IMPLEMENTATION SUBCOMMITTEE
  • Appendix B Legal Aspects of Computer-based Patient Records and Record Systems
  • STATE LICENSURE LAWS
  • Hospital Licensure Laws as Barriers to Full Automation
  • Other State Licensure Laws
  • Medicare Regulations
  • Hospital Accreditation Requirements
  • PATIENT RIGHTS ISSUES
  • Right of Privacy
  • Right of Access to Health Records
  • Ownership of Patient Data and of the Patient Record
  • Ownership of the Patient Record
  • Rights in Information Contained in the Record
  • EVIDENTIARY ISSUES
  • Importance of Admissibility of Patient Records as Evidence
  • Rule Against Hearsay
  • Definition of Hearsay
  • Business Records Exception
  • Best Evidence Rule
  • RISKS ARISING FROM COMPUTER-BASED PATIENT RECORD SYSTEMS
  • Breaches of Confidentiality and Unauthorized Access
  • Computer Viruses and Other Computer Sabotage
  • Potential for Inaccessibility
  • Questions of Durability
  • Accuracy Issues
  • Selected Legal Issues in Computer Contracting
  • OVERCOMING LEGAL BARRIERS TO COMPUTER-BASED PATIENT RECORDS AND RECORD SYSTEMS
  • Adoption of Uniform National Licensure Standards and Health Information Laws
  • Overcoming Special Legal Risks Related to Computer-based Patient Records
  • CONCLUSION
  • Index.

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