Patient Records and Computers An Editorial Submitted to the Annals of Internal Medicine October 1991

Improvement in clinical information-management systems is frequently cited as one strategy for coping with the cost and inefficiency of our health-care system. However, dissemination of computer-based records has been slow and fraught with logistical complications. The Institute of Medicine (IOM) recently undertook an 18-month study to examine the status of patient records and of computer-based approaches to their management. The study examined current and future users and uses of patient records plus technologies to support record automation. Strategies were then developed to address the barriers to widespread adoption of computerbased records. Solutions depend on a coordinated national, regional, and institutional approach to computing and communications infrastructure. Physicians may wish to familiarize themselves with the final report, in which the IOM has recommended that the public and private sectors join in establishing a Computer-Based Patient Record Institute to promote and facilitate development, implementation, and dissemination of computer-based records. Patient Records and Computers Among the diverse strategies for coping with the cost and inefficiency of our health-care system, improvement in clinical information-management systems is frequently cited (1,2). Any clinician can testify to the wasted time and poor communication among providers that can arise because of antiquated paper records that still predominate in our offices and on the hospital wards. Problems with the paper record recur on an almost daily basis. Mr. Jones arrives in the office for a consultation, but the outside records have not arrived. Mrs. Smith was discharged from the hospital last week and returns for a followup appointment, but the inpatient chart and discharge summary are not available or cannot be located. Equally exasperating is the time required to find information in the chart. Illegible handwriting, missing reports, and pages filed out of chronological order all conspire against the best intentions of providers hoping to find relevant clinical information. Furthermore, while one physician has the chart in the clinic, it is unavailable to other clinical, billing, or qualityassurance groups who may also need access to the information that it contains. Such access to longitudinal patient information is especially important for an aging, mobile society in which chronic diseases increasingly predominate as the focus of ongoing care. Challenges to our approaches to medical-record keeping are not a recent phenomenon. Weed's influential problem-oriented record is now almost 25-years old (3), and critiques of the medical chart occur frequently in the clinical literature (4-7). However, a "general air of guiltless acceptance of the inadequacy of the records" is a common attitude (8). Computerbased experiments in medical-record storage and management date back to the 1960s, but despite several successful systems (1,2,9), dissemination of such methods has been slow and fraught with logistical complications. The technologies often transfer only with difficulty from one institution to another, and incompatibility between computer-based records and other clinical or administrative information systems is a common complaint. The Institute of Medicine (IOM) is concerned about the slow adoption of technological solutions to the problems of paper records, and is convinced that the nation's medical records are contributing to our current health-care crisis (10). The organization therefore recently undertook an 18-month study to examine the status of patient records and of computer-based approaches to their management (11). The Committee on Improving the Patient Record sought to identify the various users and uses of the patient record, to survey the role and emerging capability of computers to support those uses, to identify the barriers to more widespread adoption of patient-record systems, and to recommend strategies for overcoming those barriers. Primary users of the medical record (those who care directly for patients) often forget (or disregard) the other legitimate users of patient records who depend on accurate, complete, and accessible information. Secondary users include insurers, regulatory agencies, clinical researchers, hospital administrators, epidemiologists, and numerous other health-industry professionals who have a vested interest in the quality of the record and in the efficiency with which it can be accessed and shared. Although there are serious and justifiable concerns regarding the confidentiality and security of patient information in computer-based records, mechanisms to safeguard such information, or to strip patient identifiers from pooled data, exist and can be mandated to reduce breaks in security and to allay concerns about inappropriate access to private medical information. Physicians have vast unmet but well-documented information-access needs that plague them while they care for patients (12,13). Many of these needs could be effectively addressed by computers. Expecting physicians to use computers routinely, however, is only reasonable if systems provide a critical mass of capabilities which efficiently serve the needs of clinicians (14). Networked workstations, for example, could be used not only to retrieve patient records, but also to provide integrated access to the medical literature (for example, MEDLINE in its many forms) and to provide decision-support capabilities (for example, diagnostic tools, therapy advisory systems, and programs for browsing specialized clinical knowledge bases) (15). The user interface plays an important role in the acceptance of computers by physicians. The popularity of personal computers grew with the advent of graphical interfaces and a single metaphor (such as the Apple MacintoshTM "desktop" with pictures corresponding to folders or file cabinets), and physicians are clearly demanding non-keyboard methods for interacting with computers. Recently announced pen-based computers (clipboard-sized devices that interpret handwritten characters as the user "writes" on a display screen) are likely to complement mouse-style interfaces in the near future, and ongoing research on speech understanding holds great promise as well (16). With greatly improved interfaces already available, however, information systems must be introduced to help practicing physicians access and manage clinical information more effectively. In addition to their role in enhancing patient care, electronic patient records will facilitate clinical research. Consider, for example, the nation's current high-priority efforts to improve our assessment of clinical outcomes and to develop valid management guidelines (17). Until computer-based record keeping is the norm, gathering pooled outcomes data for common disorders such as prostatic hypertrophy, cataracts, and degenerative hip disease (three areas of recent close scrutiny) will depend on labor-intensive, error-prone, manual data abstraction and reentry (18). Even more problematic is the dissemination of guidelines back to the primary providers of care. Current plans depend almost entirely on publication of guidelines, despite the recognized inability of clinicians adequately to read and absorb the relevant clinical literature. Suppose, instead, that panels of clinicians, using computer-based records interconnected through national networks, provided routine real-time collection and pooling of outcomes data as an automated byproduct of the patient-care process. Not only would the pertinent outcomes data and care decisions be gathered automatically, but the same computer systems could provide a mechanism for delivering established guidelines back to the point of care when they are needed. By analogy, this approach could be extended to other forms of clinical research, including multi-institutional trials and studies by the pharmaceutical industry. Such strategies also hold great promise to reduce the time currently spent by clinicians on administrative details related to the patient record and to the organization of information stored within it. The obvious appeal of using computer-based techniques to solve both local and national issues in clinical data management motivated the IOM committee to seek methods to catalyze change. The committee's vision of the future is possible with current technology, but it depends on a coordinated national, regional, and institutional approach to computing and communications infrastructure for the biomedical community. The IOM committee, acknowledging that there is no national organization with a current mandate to oversee and coordinate the logistical issues involved in defining the infrastructure for computer-based patient records, has recommended that the public and private sectors join in establishing a Computer-Based Patient Record Institute to promote and facilitate the development, implementation, and dissemination of such records (11). Combined with an unequivocal call for the adoption of computer-based records on a national basis, the IOM recommendations cite the need for improved standards for connecting machines to one another and for sharing data. Such standards will help assure that vendors and other system developers provide compatible systems that can share information across institutions. Although the IOM's published report and detailed recommendations did not appear until early autumn (11), a coalition of public and private organizations has already spent the summer gathering support for the creation of such an institute (19). Its success will be highly dependent upon a broad base of participating professional, governmental, commercial, and patient-advocate organizations. Making informed patient-care decisions depends on timely access to and management of patient information. Gaining this access is intimately tied to the development of a national biomedical information-management infrastructure. Thus, th