BOX 2-3
USER REQUIREMENTS FOR PATIENT RECORDS AND RECORD SYSTEMS
Uniform core data elements
Standardized coding systems and formats
Common data dictionary
Information on outcomes of care and functional status
"Front-page" problem list
Ability to "flip through the record"
Integrated among disciplines and sites of care
Rapid retrieval
24-hour access
Available at convenient places
Easy data input
Linkages with other information systems (e.g., radiology, laboratory)
Transferability of information among specialties and sites
Linkages with relevant scientific literature
Linkages with other institutional databases and registries
Linkages with records of family members
Electronic transfer of billing information
Decision support
Clinician reminders
"Alarm" systems capable of being customized
"Derived documents" (e.g., insurance forms)
Easily customized output and other user interfaces
Standard clinical reports (e.g., discharge summary)
Customized and ad hoc reports (e.g., specific evaluation queries)
Trend reports and graphics
Easy access for patients and their advocates
Safeguards against violation of confidentiality
Minimal training required for system use
Graduated implementation possible
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