. "5 Improving Patient Records: Conclusions and Recommendations." The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press, 1997.
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The CPR states the logical basis for all diagnoses or conclusions as a means of documenting the clinical rationale for decisions about the management of the patient's care. (This documentation should enhance use of a scientific approach in clinical practice and assist the evolution of a firmer foundation for clinical knowledge.)
The CPR can be linked with other clinical records of a patient—from various settings and time periods—to provide a longitudinal (i.e., lifelong) record of events that may have influenced a person's health.
The CPR system addresses patient data confidentiality comprehensively—in particular, ensuring that the CPR is accessible only to authorized individuals. (Although absolute confidentiality cannot be guaranteed in any system, every possible practical and cost-effective measure should be taken to secure CPRs and CPR systems from unauthorized access or abuse.)
The CPR is accessible for use in a timely way at any and all times by authorized individuals involved in direct patient care. Simultaneous and remote access to the CPR is possible.
The CPR system allows selective retrieval and formatting of information by users. It can present custom-tailored "views" of the same information.
The CPR system can be linked to both local and remote knowledge, literature, bibliographic, or administrative databases and systems (including those containing clinical practice guidelines or clinical decision support capabilities) so that such information is readily available to assist practitioners in decision making.
The CPR can assist and, in some instances, guide the process of clinical problem solving by providing clinicians with decision analysis tools, clinical reminders, prognostic risk assessment, and other clinical aids.
The CPR supports structured data collection and stores information using a defined vocabulary. It adequately supports direct data entry by practitioners.
The CPR can help individual practitioners and health care provider institutions manage and evaluate the quality and costs of care.
The CPR is sufficiently flexible and expandable to support not only today's basic information needs but also the evolving needs of each clinical specialty and subspecialty.
The committee believes that the CPR can be well established within a decade in the majority of offices of physicians, dentists, and other health care professionals and in clinics, hospitals, and multifacility provider institutions. Achieving such widespread use in only 10 years is an ambitious goal, but it can be accomplished if two conditions are met. First, a concentrated effort—with appropriate leadership, resources, coordination, and incentives—must be mounted. Second, CPR systems must be affordable and at least minimally acceptable to users.