BOX 2-3
USER REQUIREMENTS FOR PATIENT RECORDS AND RECORD SYSTEMS

Record Content

Uniform core data elements

Standardized coding systems and formats

Common data dictionary

Information on outcomes of care and functional status

Record Format

"Front-page" problem list

Ability to "flip through the record"

Integrated among disciplines and sites of care

System Performance

Rapid retrieval

24-hour access

Available at convenient places

Easy data input

Linkages

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

Intelligence

Decision support

Clinician reminders

"Alarm" systems capable of being customized

Reporting Capabilities

"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

Control and Access

Easy access for patients and their advocates

Safeguards against violation of confidentiality

Training and Implementation

Minimal training required for system use

Graduated implementation possible

In compiling the list of user requirements, the committee noted two special considerations. First, user needs can conflict with each other—not just among groups (e.g., patients and practitioners need confidentiality, but claims payers seek access to detailed clinical information), but also within a single user group (e.g., doctors want access to information to be very fast, but they may also want to be able to sort information according to complicated logical rules, which slows response times). To the extent possible, the committee resolved such conflicts by using sensible rules of priority. In



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