only to those with a need to know and to certify their identity before permitting access. In addition, the CPR system must be capable of providing different levels of data confidentiality as required for its various users. Audits of all legitimate users of CPR systems must be conducted regularly to remind and assure patients and staff that strict confidentiality is being maintained and measured. Such periodic audits should help deter any attempts by staff to breach confidentiality.

Members of the health care team who record patient data in the record are responsible for such entries, but in a hospital or clinic, physicians typically still have primary responsibility for ensuring the record's accuracy. As documentation of health care shifts from paper to computer-based records, practitioners will maintain their responsibility to document patient care, but the data will reside within CPR systems. Legal, professional, and accrediting standards must be revised to specify appropriate new roles and responsibilities associated with the shift from the paper chart to the CPR.

In the aggregate, current CPR systems seem to use limited measures for ensuring patient confidentiality. Most CPR systems do not approach the levels of security or confidentiality that airlines or banks, for example, maintain to protect their less sensitive information. Future CPR systems must implement stricter measures to protect confidentiality (National Research Council, 1991).

Linkages to Secondary Databases

Many clinically relevant registries and databases have evolved in recent years and are of particular interest to health care professionals as they attempt to improve the quality of patient care. Increasingly, these collections of secondary data will be extracted from primary data in CPRs in such a way as to protect the confidentiality and identity of individual patients. Thus, patient records will collect all data on all problems for a single patient; clinical research databases will collect all data on one problem for many patients. For policymakers, the secondary collection of relevant (nonconfidential) clinical information on large populations of patients will support their development of policy strategies and general assessments of quality and outcomes of care. Hundreds of databases are available or are now evolving; some of these resources should be linked with the CPR to provide clinical decision support when needed.

Some current CPR systems already offer linkages to knowledge and research databases. Most CPR systems, however, lack this capacity, owing primarily to the complexity and cost of developing such linkages. Health care professionals are beginning to appreciate the support offered by timely access to a diverse array of external information sources in providing care.

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