. "2 The Computer-Based Patient Record: Meeting Health Care Needs." The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press, 1997.
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EFFICIENCY Users want to minimize expense, effort, complexity, and waste. To achieve such efficiencies, computer-based patient record systems must include certain capabilities—in particular, one-time data entry and performance of routine tasks. Further, CPR systems should be designed so that data content is streamlined and unnecessary data are not collected.
Any data entered into the system should be available for a variety of uses, eliminating the need for redundant data entry. (The need for manual extraction of data and re-entry procedures greatly diminishes the value of a system.) The system should be designed to ensure that data are available to support patient care, organizational operations, and decision making. Thus, data must be viewed as an organizational resource, not property "owned" or controlled by the departments that happen to collect them or that are the primary users of the data.
The CPR system should be a part of an integrated patient care information system. If the system is hospital based, it should communicate with systems in the clinical laboratory, pharmacy, respiratory therapy, other ancillary services, referring physician offices, and other care settings (e.g., home, nursing home) so that data will not require manual transcription from one system to another. If the system is based in a physician's office, it should communicate with the computer systems of local clinical laboratories, pharmacies, hospitals, and other physicians' offices.10
CPR systems should facilitate the movement of data into, within, and outside of the automated patient record. In particular, they should permit raw and aggregated data to be moved to another electronic database for further analysis and storage. For example, a hospital or individual physician should be able to extract selected information electronically from a patient care database to send to other internal or external (perhaps national) databases.11 In addition, the system should have no trouble accepting data directly from electronic monitoring devices and other patient care equipment.
Health care professionals perform many routine administrative tasks in the course of providing services, and they seek ways to reduce this administrative burden so that they can devote more time to direct patient care, research, and education. Patient record systems should provide the capacity to generate routine documents based on record data automatically, to submit insurance claims electronically, and to report adverse reactions or occurrences of tracked diseases automatically.
Computer-based records must be designed to avoid the mere replication
Requiring such communication within and between institutions increases the complexity of achieving adequate security measures to maintain confidentiality.
This data transmittal capability assumes that adequate security measures are in place.