1991). First, automated patient records can improve health care delivery by providing medical personnel with better data access, faster data retrieval, higher quality data, and more versatility in data display. Automated patient records can also support decision making and quality assurance activities and provide clinical reminders to assist in patient care. Second, automated patient records can enhance outcomes research programs by electronically capturing clinical information for evaluation. Third, automated patient records can increase hospital efficiency by reducing costs and improving staff productivity.
Several sources support these conclusions. The GAO reported that an automated medical record system reduced hospital costs by $600 per patient in a Department of Veterans Affairs hospital because of shorter hospital stays (GAO, 1991). Reductions in the length of inpatient stays were also found in other studies of computerized medical records and medical record summaries (Rogers and Haring, 1979). Other investigators found enhanced care and improved outcome of care for clinic patients (Rogers et al., 1982) and a reduction in medication errors (Garrett et al., 1986).
The first step toward patient record improvement is a close examination of the users of the patient record, the technologies available to create and maintain it, and the barriers to enhancing it. To that end, the Institute of Medicine (IOM) of the National Academy of Sciences undertook a study to recommend improvements to patient records in response to expanding functional requirements and technological advances. 2 This report is the product of the multidisciplinary panel's 18-month study of how patient records can be improved to meet the many and varied demands for patient information and to enhance the quality of patient care and the effectiveness and efficiency of health care delivery.
The idea for this study originated in discussions between staff at the National Institutes of Health (NIH) and IOM. The NIH staff were involved in patient care, teaching, and research and were motivated by the need to make patient records more useful for all of these purposes. The IOM
The IOM committee was originally named the Committee on Improving the Medical Record in Response to Increasing Functional Requirements and Technological Advances. The committee's first action was to change "medical" to "patient" in its name, reflecting its consensus that the medical component of the record does not constitute the total record. Thus, this report generally will refer to what are commonly called medical records as "patient records.'' There are several instances, however, in which the committee continues to refer to medical records rather than patient records. For example, the committee's official charge relates to medical records, and the committee has not undertaken to rename "medical record professionals."