Institute of Medicine Report on Computer-Based Patient Records

Organization

The record should be organized around a list of active and inactive problems. The record should document health status, functional level, and the logical basis for all diagnoses and treatments. Records must support links to information held at other sites to create a truly longitudinal view of the patient.

Security & Accessibility

CPR systems should take a comprehensive approach to security and confidentiality while records remain constantly available for patient care.

Data Collection & Retrieval

Data contained in the CPR should be structured using a defined vocabulary. Practitioners should enter data directly into the CPR whenever possible. CPR systems should not only collect data; they should provide facilities for the selective retrieval and formatting of patient information as well.

Additional Features

The authors feel that the CPR will open new areas of inquiry and ultimately improve patient care. They require that CPR systems be linked to local and remote decision support databases. They also specify support for clinical reminders, risk assessment, quality control, cost evaluation, and outcomes research. Health care professionals and organizations should adopt the computer-based patient record as the standard for all records related to patient care.

• Health care professionals and organizations should adopt the computer-based patient record as the standard for medical and all other records related to patient care.
• To accomplish the above recommendation, the public and private sectors should join in establishing a Computer-Based Patient Record Institute (CPRI) to promote and facilitate development, implementation, and dissemination of the CPR.
• Both the public and private sectors should expand support for the CPR and CPR system implementation through research, development, and demonstration projects. Specifically, the committee recommends that Congress authorize and appropriate funds to implement the research and development agenda outlined herein. The committee further recommends that private foundations and vendors fund programs that support and facilitate this research and development agenda.
• The CPRI should promulgate uniform national standards for data and security to facilitate the implementation and dissemination of the CPR and its secondary databases.
• The CPRI should review federal and state laws and regulations for the purpose of proposing and promulgating model legislation and regulations to facilitate the implementation and dissemination of the CPR and its secondary databases and to streamline the CPR and CPR systems.
• The costs of CPR systems should be shared by those who benefit from the value of the CPR. Specifically, the full costs of implementing and operating CPRs and CPR systems should be factored into reimbursement levels or payment schedules of both public and private sector third-party payers. In addition, users of secondary databases should support the costs of creating such databases.
• Health care professional schools and organizations should enhance educational programs for students and practitioners in the use of computers, CPRs, and CPR systems for patient care, education, and research.