Computer-Based Patient Records

Interesting Facts

1. 11% of laboratory tests must be reordered due to lost results (Institute of Medicine,1996)
2. 30% of treatment orders are not documented at all (IOM, 1996)
3. Physicians spend 35% of their time doing paperwork (US Dept. of Commerce, 1996)
4. Between 20 and 30% of national healthcare expenditures are associated with informational paperwork (IOM, 1996)
5. 50% of paper-based medical records are either missing or contain incomplete data (The Workgroup for Electronic Data Interchange, 1996)

Current State of CPR Systems

At this very moment, health care worldwide is  experiencing the onslaught of new paradigms:

1. Evidence-Based Medicine
2. Medical Education
3. Technological Change
4. Evolving Standards of Care
5. Changing Roles of Traditional Stakeholders
6. Globalization

Escalating costs approaching $1 trillion in the 1990s have triggered a call from various stakeholders in health care for  mechanisms to curb unwanted expenses, bad debts and inefficient health care delivery systems.  Health care continues to evolve as it is driven by market-driven forces, alliances and mergers, and developments in software and hardware technology bringing about cost-efficient deployment of information systems.  This evolution will surely continue to push developments in CPR systems to the limits.

Managed care has shifted several aspects of care delivery such as (1) underlining the importance of primary care providers as gatekeepers to specialty care and special diagnostic tests, and (2) transferring more of the care outside of the hospital (Ambulatory care). Alliances and mergers have resulted in the integrated delivery of services, thereby streamlining the procedural aspects of obtaining health care into a seamless, comprehensive entity.  This has opened possibilities for more comprehensive assessments and evaluation of the quality of care and hence,  higher level organization and development of standards of care. Developments in computer hardware and software occuring at blazing speeds, together with widespread connectivity through local area and wide area networks and the Internet have brought about (1) new tools with which to enable care providers to have access to huge, untapped information resources, and (2) the possibility of accessing patient records from anywhere in the world and from a variety of platforms of hardware and software.

Having these developments at hand, the concept of a CPR system has evolved to include five important ingredients characteristic of functional needs of its end-users, in particular:

1. Integrated view of patient data
2. Access to knowledge resources (guidelines, rules, regulations, medical literature)
3. Physician order entry and clinician data entry
4. Integrated communications support
5. Clinical decision support (drug interaction and abnormal laboratory test alerts, trend analysis, matching to clinical practice guidelines, critiquing systems)

At the present stage of development, CPR systems are being adopted by only few health care institutions considering that the driving forces for its adoption are already existent and the continued use of paper-based systems are becoming more non-viable.

Barriers and Challenges to Implementation and Use

Important barriers to adoption of CPR systems are:

1. Lack of a common definition of and specificiations for CPR systems and standards
2. Present CPR systems are not designed to meet user needs
3. Lack of data standards (content, vocabulary and data format)
4. Legal and social issues
5. Costs and benefits
6. Leadership issues

Design and Implementation of CPR Systems

There are 5 conditions identified by the IOM study committee that will contribute to the success of CPR systems:

1. The uses of and demands for patient data are growing.  Health services research and the increased focus on content and value of therapies are a source of push in this direction.
2. We now have more powerful and affordable technologies brought about by economies of scale in utilization and production of IT products.
3. Computers inadvertently increase efficiency in virtually all aspects of everyday life.
4. The increasing mobility of Americans, the increase in the patient population with chronic diseases, the connectivity  of open systems and interoperable network systems provide a ripe environment for managing large amounts of information over geographic and political boundaries.
5. Reform in health care to make it more responsive to patient needs, as well as, more manageable financially and organizationally requires automation records management.

The IOM study committee also identified 5 objectives for future CPR systems.  CPR systems should:

1. Support patient care and improve its quality
2. Enhance productivity of health care professionals and reduce administrative costs associated with health care delivery and financing
3. Support clinical and health services research
4. Accommodate future developments in health care technology, policy, management and finance
5. Have mechanisms in place to ensure patient data confidentiality at all times

If users are to derive maximum benefit from the use of CPR systems, they must satisfy the following conditions:

1. They must have confidence in the data.
2. They must use the data actively in the clinical setting.
3. They must have the orientation that what they are using is not just a repository of patient data but a whole new resource combining tools that will enable them, for example, to get additional information, or make better decisions.
4. They must be proficient in the use of these CPR systems as well as the tools referred to above.

Patient Care Information System Strategy

Development of a patient care information systems should be viewed more as a journey rather than a specific destination.  Being a journey, the patient care information system strategy now serves as a road map containing both the theoretical (conceptual design) and practical (technical, functional and operational design) aspects.   This road map should contain the following:

1. Conceptual overview
   • Vision statement - theoretical framework, explains the intent of the IS
   • principles that govern the IS - maybe theoretical or precise, links institutional objectives with IS direction, also describes what the IS is not
   • Assumptions - assists in describing the organizational model and the environment in which it functions, as well as the interfaces and the potential problems
     
2. Functional strategy
   • Generic clinical functions of the organization
   • Specific clinical functions grouped by categories
   • Functional model - shows interrelationships among application areas and its current level of development (not automated, moderately supported, well supported)
   • Operational prerequisites - must be in place before IS implementation
   • Support role view - how new and existing applications support key patient care delivery roles
     
3. Technical strategy
   • Overview of technical environment - should be conducive for both novice and experienced system user
   • Technical characteristics of the infrastructure
   • Technical standards (e.g., HL-7)
   • Integration considerations - particularly for heterogeneous systems and scalability and ability to integrate different ISs in the future
   • Evaluation criteria (ability to meet functional user requirements, availability for access, performance characteristics, technical resource consumption, business resumption considerations, cost)
   • Principles - flexible, open standards
     
4. Acquisition strategy
   • Well-defined and thorough process, considering long-term potential
   • Principles: enhance value of IS to physicians, maintain stable operating environment
   • Ground rules for in-house development and outside sourcing
   • Selection criteria for outside sourcing: functional integration, independent and relative functionality, growth in volume and functionality, closeness to technical strategy, level of complexity, historical vendor performance, technical vendor support, vendor's projected stability for the next 5 years
   • Guidance regarding use of organization as test site for vendor products (risk, frustration of users)
   • References to organization's system development methodology
     
5. Migration strategy
   • Sequence of and processes for application implementation
   • Discrete project tasks (infrastructure building, new application systems implementation, organizational changes), task prioritization and risk assessment (technical, functional, implementation risks) for each task
   • Risk assessment based on: evaluation of stage of development of technology, information collected for functional and technical plans and experiences of other institutions regarding same projects
   • Minimize new capital investment
     
6. Operational and maintenance strategy
   • Evaluation of utilization
   • Improvements in IS with changes in health care delivery processes, enhancements to clinician interaction (voice-processing) and technological developments
   • Approaches to dealing with system maintenance: application of software releases when functionally stable, release concept of modifications and enhancements
   • Responsibilities of the user, managers and vendors
   • Concept of operations - changes to be anticipated in operations once system is implemented
     
7. Implications/Impact
   • Management concerns
   • Implications: "sum-of-parts" system (view of totality), "ownerless" system (concerted management), precedence over grassroots efforts (to provide wholeness)

Coding and Classification

Coding of medical data is done for the following reasons: (1) data reduction, (2) standardization of terminology, (3) enabling research, (4) support of management and planning, (5) coupling with decision support systems and knowledge sources. In the process of classification, we create an ordered system of concepts within a domain using ordering principles. A domain could be any of the following: reason for encounter (RFE), diagnosis, medical procedure, or it could be any other concept related to patient care and to the patient himself. Classifications can use one or more ordering principles, which are usually any of the following: anatomic location, etiology, morphology and dysfunction. Each ordering that we make using one principle is called an axis. A thesaurus is a list of terms used for a certain domain, should be complete for every domain and should contain a list of synonyms for each term. In a nomenclature, codes are assigned\ to medical concepts and these, then, can be combined to form other concepts (compare with classification where codes are predefined for all possible conditions). In classifications, classes are defined by codes. Coding is the interpretation of the aspects of an object and are formed using numbers, letters or both. Codes are of the following types: number, mnemonic , hierarchical (parent-child), juxtaposition (segments), combination (medical procedure codes), and value addition codes (powers of 2). Two more terms deserve mention here and these are taxonomy, the theoretical study of classification or the science of classification, and nosology, the science of classification of diseases, or more specifically, diagnostic terms. See Table 4 for Classifications and Nomenclature.

© 1999 Herman D. Tolentino, MD