Computer-Based Patient Record An Essential Technology for Health Care (1991) / Chapter Skim
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THE ROAD TO CPR IMPLEMENTATION
THE ROAD TO CPR IMPLEMENTATION
Pages 94-197
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From page 94... ...
The plan includes a discussion of the various organizations that have a role to play in CPR development and diffusion, the types of activities that would facilitate patient record development, how such activities might be implemented, and when such activities should take place. Chapter 5 presents the committee's formal recommendations for achieving the primary goals of the plan.
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From page 95... ...
Understanding the diverse set of CPR user needs requires that representatives of all users be involved in a process of setting priorities for system functionality and performance. 1As discussed in Chapter 1, the committee's definition of a CPR is an electronic patient record that resides in a system specifically designed to support users through the availability of complete, accurate patient data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.
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From page 96... ...
However, the uniform core data set should not be so large that it requires health care professionals to collect information that does not derive directly from routine service provision. Moreover, because providers are likely to require data elements in addition to those in the uniform core data set, CPR systems should be flexible and not be limited to core data elements.
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rather than on CPR systems. MIS development costs and time estimates, however, do convey a sense of the magnitude of CPR development costs and time.
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. Other factors also affect CPR adoption and use, including the environment of the health care system; leadership; user behavior, education, and training; costs; social and legal issues; and network needs.
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Under current reimbursement policies, any potential acquisition of new technology must contribute to the improvement of a provider's financial status or at least be budget neutral. It should also substantially improve patient care processes, for example, by providing clinical decision support or by giving complete record access to authorized personnel.
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[U] se of the medical records is not properly appreciated.
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In addition to education, practitioners need incentives to use CPRs to enter data and maintain patient records. Perhaps the greatest motivation for practitioners to use CPRs would be to produce evidence that CPRs can help to improve the quality of patient care and reduce the administrative burdens they currently face.
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Nonclinical data users (e.g., third-party payers and researchers) could also incur costs from CPR implementation.
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. The wide variation among states in hospital licensure requirements for medical records makes it difficult to develop CPR systems that comply with licensure laws in all 50 states; this factor in turn hinders the development of CPR formats that can be used nationally.
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A consistent personal identification number (PIN) in all patient records would facilitate record linkage across time and provider institutions (National Center for Health Statistics, 1990; Washington Business Group on Health, 1989)
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Thus, liability for negligence in the use of clinical decision support systems could apply to practitioners.6 The nature and obduracy of the legal barriers to CPR implementation must be understood, underscored, and addressed. For that reason, Appendix B discusses legal aspects of computer-based patient records and record systems.
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From page 106... ...
Those in the health care field must, as a result, look to other established networks for data transmission. Internet is a loosely organized confederation of federal, regional, and local networks that are used by researchers and educators for electronic mail, software and data file transfer, graphics and image file transfer, remote computer access to supercomputers and other specialized research instruments, and remote access to computerized databases.7 An estimated 1 million researchers are active users of the academic networks that are connected to Internet.
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Change agents are individuals or organizations who have, first, a mandate related to or significant interest in CPR implementation and, second, the resources or means for effecting a change (e.g., leadership position, regulation, funding)
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108 THE COMPUTER-BASED PATIENT RECORD TABLE 4-1 Change Agents and Stakeholders Important to the Implementation of Computer-based Patient Record Systems Organization Change Agent/Scope of Influence Stakeholder Public Sector Agency for Health Care Policy and Research Centers for Disease Control Congress Department of Defense Department of Veterans Affairs Food and Drug Administration Health Resources and Services Administration Health Care Financing Administration National Institutes of Health National Library of Medicine" State health agencies State legislatures Private Sector Computer standards organizations Computer-based patient record vendors Health care professionals Joint Commission for Accreditation of Healthcare Organizations Patients Patient groups Professional associations Professional schools Provider institutions Researchers Third-party payers Universities Yes/national No Yes/national Yes/national Yes/national No Yes/national Yes/national No Yes/national Yes/regional Yes/regional Yes/national Yes/national Yes/individual Yes/national No Yes/local to national Yes/national Yes/regional to national Yes/local No Yes/local to national Yes/regional to national Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes °A specific agency of the National Institutes of Health. Health Care Professionals and Professional Associations Health care professionals bear a dual burden: they must learn to use a new technology, and they must change their behavior.
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From page 109... ...
Given patient concerns about privacy and the potential for CPR systems to increase information flow within and outside of health care provider settings, patients may distrust CPR systems. Furthermore, patients are no more likely than health care professionals to use or understand computers, let alone computer-based record systems.
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By purchasing a CPR system, provider institutions can influence CPR development and implementation in three ways. First, such action signals the market that demand for CPR systems exists.
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Within NIH, the National Library of Medicine (NLM) is in a strong position to support CPR development directly through its medical informatics program and its work on the Uniform Medical Language System (UMLS)
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The challenges to CPR implementation that are found in MCH programs are by no means unique. For CPRs to be productively and effectively developed and diffused throughout the U.S.
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programs by states participating in Medicaid.12 The act also includes provisions to conduct demonstration projects to evaluate the efficiency and cost-effectiveness of prospective DURs in patient counseling and reducing costs. Such demonstration projects, which would be overseen by HCFA, are likely to address issues of interest to CPR developers and could support CPR development efforts.
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Despite Congress's activities on behalf of improved health care, some obstacles to strong congressional support of CPR development may arise. For example, having allocated new monies to some of the efforts noted above, particularly certain parts of the AHCPR mandate, Congress may not see a need for additional specific support to improve patient records.
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From page 115... ...
They have played important roles in developing regional databases to monitor quality, manage costs, and assess clinical effectiveness.14 State governments, cabinet-level health officers, and groups such as the National Conference of State Legislators, Council of State Governments, Association of State and Territorial Health Officials, and National Association of Health Data Organizations could provide a regional perspective in national CPR efforts. In addition, states would be likely candidates for pilot regional studies or experimental prototypes.
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Their role may be to foster CPR development, acquisition, and use by setting standards for accreditation that are most effectively met through CPR systems. Vendors CPR system vendors are likely to support development if the projected demand for CPR technology seems sufficient to recoup investment and marketing costs.
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The committee believes that funding for CPR development should be a governmental priority because the CPR is essential to achieving a variety of ends desired by government (e.g., improved patient care and research)
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There is also no established mechanism for setting priorities for CPR development or for representing CPR interests on an ongoing basis. The committee believes that the establishment of a formal leadership role is essential for CPR implementation success.
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about the value of computer-based patient data in improving patient care. • Foster the CPR as the primary vehicle for collecting patient data.
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Thus, greater potential for innovation might exist in the private sector. Another disadvantage to locating leadership for CPR development within the federal government is the potential for health care providers to see such efforts as too closely aligned with government and therefore open to excessive regulation and intrusiveness.
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From page 121... ...
Private Sector Sponsorship The committee also considered a private sector, not-for-profit membership organization, similar to the Joint Commission on the Accreditation of Healthcare Organizations, to lead the CPR development effort. A decided advantage to a purely private approach is that the conversion to computerbased records would become something championed by, rather than imposed on, these organizations and their constituents.
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yet allows flexibility at the local level to foster innovation in the development and use of CPRs. Third, the committee believes that patient care should be the primary focus of CPR development and implementation.
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, which made two recommendations to the secretary of Health and Human Services. First, as part of DHHS's mandate to conduct research on outcomes of health care services, the secretary should "direct the Public Health Service, through its Agency for Health Care Policy and Research, to support the exploration of ways in which automated medical records can be used to more effectively and efficiently provide data for outcomes research" (GAO, 1991:26)
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• Health care business coalitions, chambers of commerce, and major employers could all support CPR development and implementation efforts by supporting research and pilot demonstrations as well as by developing relationships with insurers and health care provider institutions that use or support CPR systems. • Federal agencies could provide substantial funding for research and development and support standards development through funding or regulatory mandate.
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Other impediments arise from the lack of an infrastructure to support CPR development and diffusion. Such an infrastructure comprises standards for communication of data (i.e., vocabulary control and data format standards)
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Paper prepared for the Institute of Medicine Committee on Improving Patient Records in Response to Increasing Functional Requirements and Technological Advances. Anderson, J
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1991. Medical ADP Systems: Automated Medical Records Hold Promise to Improve Patient Care.
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1988. Computer-stored medical records: Their future role in medical practice.
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APPENDIX: MATERNAL AND CHILD HEALTH CARE AND COMPUTER-BASED PATIENT RECORDS As discussed in Chapter 3, much of the progress to date in implementing CPRs and CPR systems has occurred in hospitals and large multispecialty practices, particularly in health maintenance organizations. To be successful, however, CPRs and the larger computer-based systems in which they function must be useful and practical for many other types of providers, including, for instance, community-based clinics and other outpatient facilities serving either primary care or special health care needs.
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This task clearly lies within the realm of CPR development. In a related vein, special projects may be mounted to enhance familycentered and community-based health care, both within and across states.
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has mounted an interesting effort to develop a "uniform clinical data set"; although it is oriented toward hospital care (and care for the elderly) , its developmental history to date offers useful and perhaps cautionary lessons for others attempting to develop clinical data sets and data dictionaries.
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CPRs can play an important role in improving the quality of patient care and strengthening the scientific basis of clinical practice; they can also contribute to the management and moderation of health care costs. The Institute of Medicine (TOM)
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This chapter summarizes the committee's principal conclusions and presents recommendations for improving patient records (see Box 5-1)
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CONCLUSIONS Patient records are the primary repository of data in the informationintensive health care industry. Although clinical information is increasingly likely to be computerized, the current, predominant mode for recording patient care data remains the paper record.
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In addition, future patient records will provide new functions through links to other databases and decision support tools. No contemporary clinical information systems are sufficiently comprehensive to be considered full CPR systems.
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as the standard for medical and all other records related to patient care. The committee believes that future patient records must be more than a way to store patient data -- they must also support the clinical decision process and help improve the quality of patient care.
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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.
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From page 138... ...
for implementation of CPRs as standard patient records could result in a loss of momentum. In contrast, a well-coordinated effort could help to accelerate progress and secure CPR implementation within the 10-year target set by the committee.
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• Educate change agents and stakeholders (including the general public and health care professionals) about the value of computer-based patient records in improving patient care.
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A purely private sector effort also has little likelihood of success: past history shows that private sector CPR development has been fragmented, unique to particular institutions, and generally underfunded. Indeed, the base of funding in the private sector is not sufficiently solid to support a new organization at this time.
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From page 141... ...
An advisory board with representation from both the private and public sectors should also be established. Program staff would support standards activities, conduct educational programs, serve as liaisons to professional organizations and commissions, represent the health care community in National Science Foundation network discussions, advise AHCPR and other extramural funders of research and demonstration projects, and plan for the second phase of CPR development and implementation.
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Data Acquisition The single greatest challenge in implementing the CPR is to develop a technology that is sufficiently powerful and appropriate to the needs and preferences of health care professionals so that they can -- and will -- enter medical and other health care data directly into the computer. Significant new technologies (e.g., graphical user interface, voice-recognition technology, high-resolution computer displays, high-speed communication networks, and hand-held data-entry devices)
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. The lack of either of these kinds of standards will impede effective use of CPR data by clinical and nonclinical users because record content will continue to vary among practitioners and provider institutions.
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The committee urges that the NLM be granted increased funding over the same period to refine the UMLS further, particularly the vocabulary involved in patient care and access to clinical knowledge bases. The NLM is the appropriate organization to educate the health care community concerning UMLS and other clinical vocabulary activities, and it is well positioned to do so effectively.
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To remedy this inadequacy, the CPRI should become an active participant in discussions by the Federal Networking Council regarding the National Research and Education Network. Cost-Benefit Analysis In view of the substantial direct costs of CPR development and implementation, issues of cost-effectiveness are important from both institutional and societal perspectives.
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Quality Assurance The CPR can and should become a resource (with a capability far beyond that of paper patient records) for the systematic evaluation of health care practices and policies.
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To use these capabilities most effectively, the committee believes the relationship between the structure of patient records and the quality of patient care should be explored further. For example, specific elements of patient records that contribute to patient care outcomes need to be identified for incorporation into CPR systems.
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The committee also determined that the review process should include an assessment of and recommendations regarding penalties for violation of the privacy of patients or providers through unauthorized access or misuse of patient data in the CPR or other patient records.
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improved patient care resulting from increased availability of patient data, medical knowledge, and clinical aids (e.g., decision support)
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RECOMMENDATION 7. The committee recommends that health care professional schools and organizations enhance their educational programs for students and practitioners in the use of computers, CPRs, and CPR systems for patient care, education, and research.
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Future RRA roles may also emphasize maintaining the quality and consistency of CPRs to support patient care and facilitate research using patient data. SUMMARY The Institute of Medicine study committee set out to develop a plan for improving computer-based patient records and the systems in which they reside.
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The challenge of coordinating CPR development efforts in the pluralistic health care environment is great. Resources are limited and must be used wisely.
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Elaine Ullian, Faulkner Hospital, Boston, Massachusetts Mary Joan Wogan, American Medical Record Association, Washington, D.C.
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Norris,* Hill and Knowlton, Ine., Waltham, Massachusetts, and Harvard School of Public Health, Boston, Massachusetts Helmuth F
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Chair, Stanford University School of Medicine, Palo Alto, California Paul C Tang, Assistant Chair, Hewlett-Packard Laboratories, Palo Alto, California Margret Amatayakul, American Medical Record Association, Chicago, Illinois Jeffrey F
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Licensure laws applicable to health care providers, as well as reimbursement and insurance laws, all impinge on computer-based patient records, as do public health laws that require reporting of vital statistics and of various injuries and diseases. Contract law and the Uniform Commercial Code come into play in contracts for computer-based record systems.
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From page 157... ...
Hospital Licensure Laws as Barriers to Full Automation State hospital licensure laws still pose barriers to full automation of the patient record. State-to-state variances in medical records requirements and obsolete and ambiguous or conflicting laws and regulations pose obstacles to the full development of computer-based patient record systems.1 Although some state regulators may permit computerization of patient records in ways that technically are not permitted by state regulations, a health care institution 1State licensure requirements have lagged far behind the development of technology and have been criticized for so lagging for 20 years or more.
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From page 158... ...
In addition, state-to-state variations in requirements regarding the content of hospital medical records may make it difficult to develop standard formats for computer-based patient records that can be used nationally. Hospital licensure laws and regulations in many states still assume a paper patient record and at best leave the legal status of computer-based 2410 Ind.
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On the basis of this requirement, the Illinois Department of Public Health strongly discourages fully computerized medical records in hospitals.
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. A serious legal barrier to full realization of the potential of computerbased patient records is the confusion and lack of clarity in some states' standards when they are applied to computer-based medical records.
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These two requirements leave the status of outside computer services for Indiana hospitals unclear.16 Other State Licensure Laws State licensure laws and regulations applicable to a variety of other health care providers -- both institutional and individual -- typically contain provisions concerning patient records or patient information and confidences, or both. State laws and regulations with respect to licensure of institutional providers other than hospitals contain many of the same types of patient record requirements and raise many of the same issues raised by hospital licensure laws and regulations.
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From page 162... ...
Use of a rubber stamp signature, with or without initials, is not permitted. In addition, resident records must contain a "physician's order sheet," a "medication sheet," and "treatment sheets," implying that a manual record must be maintained.17 State licensure requirements for nonhospital institutional providers exhibit the same lack of national uniformity in standards for patient records exhibited by state hospital licensure requirements.
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. 26Apparently, the Health Care Financing Administration (HCFA)
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The JCAHO requires that all medical records be accurate, accessible, authenticated, organized, confidential, secure, current, legible, and complete.30 A computer-based medical record system can meet JCAHO standards if the system is properly designed and maintained and if medical records are otherwise properly completed. PATIENT RIGHTS ISSUES Right of Privacy The Federal Privacy Act and similar acts in many states provide assurance that patient records held by the federal government and governments of states that have enacted privacy legislation will not be disclosed to third parties without the patient's consent, except under defined circumstances.31 However, privacy of patient records in other states and in the private sector is governed by a crazy quilt of statutory, regulatory, and common-law rules and is often inadequately protected.32 Growing demands for information contained in patient records pose an ever-increasing threat to patient privacy.
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From page 165... ...
Thus, the lack of adequate, uniform, national protection of patient privacy with respect to patient records may hinder full development of computer-based patient record systems. The Uniform Health-Care Information Act skillfully addresses issues of confidentiality and release of patient information.33 Only Montana, however, has enacted this act into law.34 Right of Access to Health Records Most states expressly allow a patient or a patient's authorized representative to inspect and copy the patient's hospital records.35 Rights of access to health records maintained by physicians and other individual health care providers may not always be clear.
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From page 166... ...
In addition, even if the patient gains access to the record, he or she may have no legally enforceable right to correct inaccurate information contained in it. The Uniform Health-Care Information Act addresses access issues, as well as issues of confidentiality and information disclosure.41 As noted earlier, however, only Montana has adopted this legislation to date.42 Issues of access to databases maintained by insurers, correction of data maintained on individuals by insurance companies, and limitations on redisclosure of such information are addressed in the Insurance Information and Privacy Protection Model Act developed by the National Association of Insurance Commissioners (NAIC)
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EVIDENTIARY ISSUES Importance of Admissibility of Patient Records as Evidence A computer-based patient record system should be structured so that patient records created and stored on the system can be admitted as evidence in court in disputes between providers and patients or payers, in cases in which the medical condition of the patient is at issue, and in other litigation. Because records of many businesses are computerized, courts have developed standards for establishing the trustworthiness of computerized records.
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From page 168... ...
In addition, record entries must have been made at or near the time the events recorded. The identity of the person making or recording the entries must be captured in the record; in addition, the record must have been prepared by or from information transmitted by a person with firsthand knowledge of the event recorded who is acting in his or her ordinary business capacity.49 A computer-based medical record made in the normal manner at the time of delivering care should meet the requirement that a business record be kept regularly in the ordinary course of business.
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This exception to the hearsay rule is known as the medical records exception.
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In addition, the necessity of keeping records in a manner that makes them admissible as evidence in court requires a provider to protect patient records from unauthorized access. The legal duties to preserve confidentiality and prevent unauthorized access to patient records are the same with respect to both paper and computer-based records.
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From page 171... ...
Security measures that are both adequate and affordable and that do not interfere with efficient patient care currently do not exist for such systems. A computer-based patient record system should include a security system that, as far as is practicable, permits only authorized users to access patient records and permits authorized users to access only those portions of the records that are relevant to their particular functions.
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From page 172... ...
The security mechanisms available for decentralized systems and computer networks provide much less protection than those available for mainframe systems. Given current technology, the need for security generally must be balanced with the need of health care professionals and hospital staff for easy, immediate access to patient records.
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Potential for Inaccessibility Medicare, the JCAHO, and most state hospital licensure laws require that medical records for current hospital patients be readily accessible and stored in a way that permits prompt retrieval of information. Keeping computerbased patient records available means minimizing system downtime and having adequate backup mechanisms.
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The provider must also ensure that copied records comply with a state's hospital and other institutional licensure requirements as to the media in which patient records can be retained.
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. An inaccurate product definition in a contract for a computer-based patient record system or a product definition that is not sufficiently detailed can result in delivery of a system that does not function properly as a patient record system or in a contract that does not require the vendor to deliver a system that has certain important features or the capability to perform crucial patient record functions.
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From page 176... ...
Access to the source code for software is essential to a health care provider's ability to support and maintain patient record application software. Therefore, the provider should attempt to obtain a copy of the source code, either as part of the initial license grant or in the event that the vendor breaches its support obligations or decides to discontinue supporting the software.
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From page 177... ...
If enacted, these uniform state licensure standards for medical records should be applicable to all institutional health care providers that are required to maintain patient records. The problems arising from obsolete and ambiguous state licensure standards for medical records could be resolved by the development and enactment of uniform state licensure standards expressly applicable to computerbased records and record systems.
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From page 178... ...
The greatest legal risk from computerbased patient record keeping comes from unauthorized access to record systems and from computer viruses and other sabotage, particularly in cases in which computer networks are used and there is telephone access to the patient information system. Research efforts should be directed toward developing affordable computer security technology that can adequately protect patient records without severely reducing system user friendliness.
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From page 179... ...
Therefore, concerted efforts should be made to overcome legal and technological barriers that stand in the way of full development of computer-based records and record systems. In the future, with increasing use and development of artificial intelligence systems, computer-based patient records may be expected to become interactive, providing diagnostic assistance and even treatment recommendations.
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Index Academic research, 68, 70, 106, 115 Access issues, 18, 23, 30, 36, 37-39, 92, 135, 137 computer technology and, 24, 57 insurers, 36, 165, 166 legal right to, 39, 165-166, 170172, 173-174 outpatient records, 19 software source code, 176 system redundancy, fault tolerance, 74,75 system response, 39, 62, 76, 82, 101-102, 176 see also Confidentiality Accreditation, 21, 31, 33, 66, 105, 116, 124-125, 164, 170, 173, 174 Accuracy issues, 51, 66, 83, 163, 175 see also Errors and error analysis Acute disorders and care, 22, 79-80, 87 Administrative functions, 2,3,7,21, 45,49, 51,77, 137, 151 billing, 20, 34, 62, 76 costs, 2, 7, 24, 54, 149 Advocacy, patients, 109-110 Agency for Health Care Policy and Research, 22-23, 111, 120, 122, 123, 131, 140, 141 AIDS, 171 Ambulatory care records, see Outpatient records American College of Radiologists, 64 American Medical Society, 23, 162 American Society for Testing and Materials, 64 Arden syntax, 81 Artificial intelligence, 157, 179 see also Knowledge-based systems Attitudes toward diffusion of innovations, 98, 99-100, 101, 108 public, 109, 151 systems vendors, 91-93 B Bibliographic databases, 3, 25, 30, 4849,51,75, 80, 137 Billing, 20, 34, 62, 76 Case studies hospital information systems, 75-76 maternal and child health care, 129131 181
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, 68, 71-73 Computers at Risk: Safe Computing in the Information Age, 145 Confidentiality, 2, 3, 4, 23, 38, 36, 4243,51, 103-104, 109, 125, 137, 144, 148, 156, 163, 164-165, 170-172, 177-178 contract provisions, 177 design for, 95 future systems, 50 individual practitioners' patient records, 13, 23 insurer access and, 36, 165, 166 pharmacy records, 13 privacy defined, 23 secondary databases, 66 standards, 87, 144 state law, 103-104, 164-165 technological aspects, 66, 82, 8385 Connectivity, see Linkage and integration Content issues, 15, 16-17, 36 definition of, 119, 139 outpatient records, 19 standards, 19, 96, 143 tables of, in computerized records, 38 Contracts, 156-157, 175-177 Coordination, see Organizational factors COSTAR, 68, 71-73 Cost factors, 2, 5, 9, 14, 22, 24, 45, 49, 109, 110, 114, 117, 125-126, 134, 135, 137, 138, 142, 145-146 administrative, 2, 7, 24, 54, 149 clerical, 79, 97 computing technology, 25-26, 61-62, 68, 82, 83, 92, 93, 97, 102 data entry, 40, 45, 82 demonstration projects, 113 design and development aspects, 95, 96-97, 96-98, 120 diffusion of technology, 101-102 hospital systems, 9, 19, 20, 93, 97 insurers, 21-22, 101, 110, 150 malpractice insurance, 80 maternal and child health care program, 112 medical information systems, 97, 102 per patient, 9, 101 secondary databases, 6, 66, 133, 149 sharing, 6, 7, 133, 121-124, 139, 149-150, 152 standards, 102 technological innovations, general, 25-26, 61-62, 68, 82, 83, 92, 93, 97, 102 voice recognition, 83 Council on Ethical and Judicial Affairs of the American Medical Association, 162 Court cases, see Litigation
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INDEX 183 D Database management systems, 57, 5960, 135 specific, 67-81 Databases, 6, 57-59, 104, 106, 135 AM A guidelines, 162 bibliographic, 3, 25, 30, 48-49, 51, 75, 80, 137 federal role, 23 linkage of, 5, 25, 44, 45, 51, 61, 6263, 66-67, 80; see also Networks problem-oriented medical record, 47 query languages, 62, 73 secondary, 5, 6, 11-12, 25, 30, 51, 33-34, 54, 66-67, 80, 117, 119, 133, 135, 137, 138, 139, 147-149 specific, 67-81 see also Knowledge-based systems Data entry, 73-74, 78, 81-82, 92, 93, 142 cost factors, 40, 45, 82 errors, 40, 45, 61 physician incentives, 82, 101, 124, 142 voice recognition, 62, 82-83, 87, 135, 142 Data quality, 40-42 Data retrieval, 3, 4, 9, 61-62, 67, 135, 137 Data storage, general, 37-46, 67 Decentralized Hospital Computer Program, 76-77 Decision support and problem solving, 7, 9, 11, 17-18, 19-20, 24-25, 30, 37, 40, 46-49, 51, 61, 68, 73, 80-81, 92, 105, 137, 179 knowledge-based systems, 30, 44, 48, 51, 61, 66, 75, 80-81, 137 Defense Advanced Research Projects Agency (DARPA) , 106 Definitional issues, 11-12, 46, 51, 119, 139 contract law, 175 change agents versus stakeholders, 107, 140 computer-based patient record, 11, 51,91-92,95 data integrity, 42^-3 development versus diffusion, 94 health care needs, 30-35 hearsay, evidence, 168 patient records, 11, 51, 91-92, 95 privacy, 23 users, 31 Demographic factors, 2, 20, 22, 26, 72, 129-130, 151 see also Epidemiology Demonstration projects, 5, 6, 23, 113, 116, 117, 119, 124, 138, 139, 141, 142 Department-level information systems, hospitals, 68, 69, 92 Department of Defense, 77, 85-86, 97, 106, 113, 121, 122, 131 Department of Energy, 106 Department of Health and Human Services, 111, 120, 123, 141 see also specific subordinate agencies Department of Veterans Affairs, 76-77, 85-86,97, 113-114, 121, 122, 131 Design and development, 5, 7, 23, 56, 94-98, 94-98, 107-125, 138, 141 costs, 95, 96-97, 96-98, 120 defined, 94 modular, 72, 76-77, 80-81 problem-oriented medical record, 47 for system phasing, 49 Dictionaries, see Vocabulary control Diffusion, innovations, 1, 4-5, 25, 95, 98-107, 125, 138 attitudes, 98, 99-100, 101, 108 costs, 101-102 defined, 94 insurers, 99, 101, 102, 110-111 see also Education and training; Professional education DIOGENE, 78, 83 Drugs, see Pharmacies and pharmaceuticals
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From page 184... ...
184 INDEX E Early Clinical Information System, 76 Economic issues physician incentives, data entry, 82, 101, 124, 142 productivity, 2, 24, 50, 110, 149 see also Cost factors; Financial factors; Funding Education and training, 5, 7, 23 change agents and stakeholders, 119, 139 diffusion of innovations, general, 98, 99-101, 102, 117 patient, 31, 39 users, general, 5, 39, 99-101 see also Professional education Efficiency/effectiveness, 9, 14, 22, 23, 45-46, 51, 83, 117, 119, 123, 135 system response time, 39, 62, 76, 82, 101-102, 176 Electronic mail, 3, 75, 106, 145 Emergency care, see Acute disorders and care Employers and employment, 22, 110111 Encounter-oriented medical records, 71 Epidemiology, 44, 83 national, 22, 111, 130 risk factors, 22, 40, 49 Error and error analysis, 175 data entry, 40, 45, 61 on-line, 46, 61 voice recognition, 83 see also Accuracy issues Evaluation, 31, 138 computer applications costs, 97 data validity tags, 43 of patient care, defined, 12 peer review, 21, 113 reliability of records, 15, 37, 65-66 see also Efficiency/effectiveness Event-oriented medical records, 73 Exmouth Project, 78-79 Expert systems, see Knowledge-based systems Federal government, 6, 21, 22-23, 7677, 111-114, 117, 120-124, 129131, 140-141 Computer-based Patient Record Institute, 6, 123, 124, 133, 138, 139-141, 143, 144, 145, 147151 cooperation with public sector, 87, 121-124, 138, 140, 141 funding, 6, 111, 120-124, 140-141 interagency coordination, general, 131, 140, 141 national information system, 6, 5154, 122-124, 125, 129, 130, 133, 138-141, 145 organizational role, general, 22-23, 131, 140, 141 research, 23, 111, 120-121, 130, 131 standards, 22, 23, 85-87, 111, 117 see also Laws, specific federal Federal Networking Council, 106, 145 Federal Privacy Act, 164 Financial factors, 2, 5, 7, 21, 38, 54, 75-76 federal role, 21,22-23 see also Billing; Cost factors; Funding; Insurance and insurers Flexibility, 43, 69, 93, 135, 137 Flow sheets, 17 Food and Drug Administration, 104105, 141, 145 Foundations, 117, 119, 141, 145 Format issues, records, 15, 17-18, 36, 46-47, 71 outpatient records, 19 problem-oriented, 17-18, 46-47, 49, 71, 73, 80 standards, 19, 96, 142, 147 tables of contents/indexes, 38 Funding, 5, 6, 99, 111, 117, 121, 130, 133, 135, 138, 140-141 federal, 6, 111, 120-124, 140-141 hospital systems, 97 standards development, 85
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From page 185... ...
INDEX 185 G General Accounting Office, 8-9, 97, 123-124 Government role, see Federal government; Local governments; State governments; and specific departments and agencies Graphics, 3, 49, 51, 60, 61-62, 106, 135 windowing, 73, 93 see also Images and image processing Group practices, 70-71 H Harvard Community Health Plan, 68, 71-73 Harvard Medical School, 75 HEALTH, 111 Health Care Financing Administration, 21, 85-86, 87, 112-113, 120121, 122, 131, 141, 163 Health Evaluation through Logical Processing (HELP) , 68, 74-75, 81, 83 Health maintenance organizations, 7173 Health Resources and Services Administration, 112, 129-130, 131, 141 Hearsay, evidence, 168-170 High-Performance Computing Act, 106 Historical perspectives, 4, 8, 12-13, 67-69 committee study, 9-11 COSTAR, 68, 71-73 hospital systems, 67, 97 networks, 106 THERESA, 68, 73-74 HL 7 standards, 64 Hospitals systems, 38, 45, 67, 73-77, 92 costs, 9, 19, 20, 93, 97 defined, 12 department-level information systems, 68, 69, 92 historical perspectives, 67, 97 licensure laws, 103, 157-161, 173 multi-institution, 24, 44, 76-77, 97, 113, 121 THERESA, 68, 73-74, 83 Human-computer interface, see Users Images and image processing, 20, 24, 60, 62, 63, 70-71, 106, 135, 145 see also Graphics Indexes, 38 Information Security Foundation, 145 Insurance and insurers, health, 3, 6, 2122,31, 33, 34, 114, 125-126, 133, 150 confidentiality and access by, 36, 165, 166 contract provisions, 177 cost factors, 21-22, 101, 110, 150 diffusion of innovation and, 99, 101, 102, 110-111 electronic claims submission, 45 employer provided, 110-111 health maintenance organizations, 71-73 physician incentives, data entry, 101, 124 see also Medicaid; Medicare Insurance Information and Privacy Protection Model Act, 166 Insurance, malpractice, 80 Institute of Electronic and Electrical Engineers, 143 Institute of Medicine, 1, 9-10, 15, 23, 91, 114, 132, 151 Integrated Academic Information Management System, 116 Integrated Services Digital Network, 65 Intellectual property, 176 Intelligence, 5, 36, 37 artificial intelligence, 157, 179 see also Knowledge-based systems Intermountain Health Care Corporation, 74
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From page 186... ...
M'6 INDEX International programs and activities, 78-79. 95, 143-144 Internet, 106 Joint Commission on Accreditation of Healthcare Organizations, 21, 116, 121, 164, 170, 173, 174 K Knowledge-based system, 30, 44, 48, 51, 61,66, 75, 80-81, 137 Laboratory tests, 20, 72, 79 Laws, specific federal Federal Privacy Act, 164 High-Performance Computing Act, 106 Omnibus Budget Reconciliation Act, 22-23, 113 Social Security Act, 129, 130 Uniform Health-Care Information Act, 148, 166, 178 Legal issues, 5, 98, 103-105, 117, 138, 139, 148-149, 156-179 contracts, 156-157, 175-177 evidentiary, 167-170 licensure laws, 103, 148, 156, 157162, 176, 177-178 information access, right to, 39, 165-166, 170-172, 173-174; see also Confidentiality intellectual property, 176 malpractice, 80, 100 ownership of data, 103, 148, 167, 176 systems defect liability, 105, 156 vendors, 105, 156-157, 158, 175177 viruses, computer, 173, 178 see also Laws, specific federal; Litigation; Regulations Legislation, 46 model, 6, 148-149, 166, 177-178 see also Laws, specific federal Linkage and integration, 3, 18, 36, 4345, 51, 137 confidentiality and, 103 of databases, 5, 25, 44, 45, 51, 61, 62-63,66-67,80, 135, 137; see also Secondary databases development and diffusion resources, 5, 7 financial-care information, 21 multi-site care, 24, 44, 76-77 see also Organizational factors Lockheed Corporation, 76 Licensure laws, 103, 148, 156, 157162, 176 national, 177-178 Litigation, 21, 35 contracts, 175 evidentiary issues, 167-170 systems defect liability, 105, 156 Longitudinal approaches, 22 institutional planning, 21 patient records, 3, 4, 17, 22, 24, 130 M Malpractice, 80, 100 Management of care, general, 21, 34, 49, 50; see also Administrative functions Maternal and child health care program, 112,129-131 Medicaid, 113, 130, 162 Medical information systems, 67 costs, 97, 102 defined, 12 Medical Logic Modules, 80-81 The Medical Record (TMR)
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From page 187... ...
INDEX 187 N National Aeronautics and Space Administration, 106 National Association of Insurance Commissioners, 166 National Conference of Commissioners on Uniform State Laws, 104 National Research and Education Network, 106-107, 145 National Electrical Manufacturers Association, 64 National Institutes of Health, 9,111 National Library of Medicine, 80, 111, 116, 122 National Research Council, 10 National Science Foundation, 106 Networks, 5,1, 24, 51, 65, 106, 142, 145 design for, 95 diffusion of innovations, 98, 105107 electronic mail, 3, 75, 106, 145 national information systems, 6, 5154, 106-107, 119, 122-124, 125, 129, 130, 133, 138-141, 145 security, 44, 52, 104, 172 standards, data exchange and vocabulary, 4, 6, 7, 41-42, 52, 62, 63-65, 72, 82, 83, 85-87, 96, 105-107, 111, 119, 124,125, 130, 131, 133, 135, 137, 139, 142144, 147-148, 152 Nurses, chart writing, time spent, 19 o Office of Technology Assessment, 97 Omnibus Budget Reconciliation Act, 22-23, 113 Organizational factors, 5-6, 7, 8, 118124, 132, 135-136, 138-139 accreditation, 21, 31, 33, 66, 105, 116, 124-125, 164, 164, 170, 173, 174 change agents and stakeholders, 107-117, 119, 122, 124-125, 135, 139, 140 Computer-based Patient Record Institute, 6, 123, 124, 133, 138, 139-141, 143, 144, 145, 147-151 cost sharing, 6, 7, 133, 121-124, 139, 149-150, 152 federal interagency coordination, 131, 140, 141 federal role, general, 22-23, 131, 140, 141 institutional planning, 21, 92 health care system, general structure, 98-99, 135 medical record practices, physicians, 15, 17, 19 private/public cooperation, 87, 121124, 138, 140, 141 professional associations, 6, 21, 23, 99, 109, 116, 121, 124, 135-137, 150, 162, 164, 166, 170, 173, 174 standard-setting organization, 126 technological innovation, 94, 107117, 124-125 see also Administrative functions; Format issues; Linkage and integration; Management of care Outpatient records, 19, 68, 97 COSTAR, 68, 71-73 summary time-oriented record, 18 Ownership issues, 103, 148, 167, 176 PaperChase, 75 Paper records, 13-19, 37, 40, 46, 134 Patient record, general, 12-13 defined, 11, 51, 91-92, 95 paper, 13-19, 37,40,46, 134 users and uses, 31-34 Patients, general, 109-110 access to information, legal right, 39, 165-166, 170-172, 173-174 cost per, 9, 101 as data users, 21, 39 education, 31, 39 see also Confidentiality Peer review, 21, 113 Personal identification numbers, 104
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From page 188... ...
, 17-18, 46-47, 49, 71, 73,80 Problem solving, see Decision support and problem solving Productivity health professionals, 2, 24, 50, 149 insurers and, 110 Professional associations and societies, 6,21,99, 109, 124, 135-137, 150, 166 AMA, 23, 162 JCAHO, 21, 116, 121, 164, 170, 173, 174 Professional education, 6, 24-25, 31, 33, 35,48-49, 115-116, 124, 125, 133, 138, 139, 150-151 academic research, 68, 70, 106, 115 diffusion of innovations, 98, 99-101, 102, 117 physicians, 39 teaching hospitals, 38 Professionals, general, 6, 7, 32, 108109, 124, 134, 136-137 licensure laws, 162 productivity, 2, 24, 50, 149 see also Nurses; Physicians; Users Projections, 12, 50-54, 137 digital switching, 65 imaging, 63 text processing systems, 62 Prospective Payment Assessment Commission, 114 Prototypes, see Demonstration projects Public Health Service, 22, 131, 141 Public opinion, 109, 151 Quality control, 31, 33, 40^* 2, 142, 146-147 accreditation, 21, 31, 33, 66, 105, 116, 124-125, 164, 164, 170, 173, 174 of care, 2, 7, 20, 24, 49, 50, 79, 101, 109, 110, 114, 134, 137, 146-146 of data, 40-42, 46 on-line, 46, 61 see also Accreditation; Error and error analysis; Regulations; Standards Query languages, 62, 73
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From page 189... ...
INDEX 189 Read Clinical Classification, 64 Real time, 67, 113 Recommendations, IOM, general, 6-7, 132-152 Redundancy, fault tolerance, 74, 75 Registered Record Administrators (RRAs) , 151 Regulations, 6, 35, 46, 103-105, 133, 148-149, 160-161 Medicare, 162-164, 170, 173 see also Licensure laws; Standards Reliability, 15, 37, 51, 65-66, 135, 174 design for, 95 see also Accuracy issues Research, 3, 4, 5, 6, 10, 24, 31, 33, 35, 66, 125, 138, 141-142, 146, 178 academic, 68, 70, 106, 115 demonstration projects, 5, 6, 23, 113, 116, 117, 119, 124, 138, 139, 141, 142 epidemiology, 22, 44, 40, 49, 83, 111, 130 federal role, 23, 111, 120-121, 130, 131 health services, support of, 1, 2, 50 problem-oriented medical record, 47 uniform record systems, 42 see also Design and development Risk factors, 22, 40, 49 Secondary databases, 5, 6, 25, 30, 51, 33-34, 54, 66-67, 80, 117, 119, 133, 135, 137, 138, 139, 147149 costs, 6, 66, 133, 149 defined, 11-12 Security, data, 42-43, 65-66, 82, 8385, 103-104, 135, 171, 170-173 design for, 95 networks, 44, 52, 104, 172 standards, 4, 6, 7, 52, 87, 119, 124, 133, 139, 142, 144-145, 147148, 152 see also Confidentiality Smart cards, 78-79 Social factors, 103-105, 112, 130 politics, 2,4-5, 109, 151 public opinion, 109, 151 Social Security Act, 129, 130 Speech recognition, see Voice recognition Stakeholders, 107-117, 122, 135, 139 Standard Guide for Nosologic Standards and Guides for Construction of New Biomedical Nomenclature, 64 Standards, 5, 6, 7, 66, 87-88, 116, 117, 119, 133, 136-137, 142-148, 177-178 accreditation, 21, 31, 33, 66, 105, 116, 164, 164, 170, 173, 174 clinical practice guidelines, 7, 23, 54, 120, 137, 146 confidentiality, 87, 144 content, general, 19, 40-42, 96, 142, 143 cost factors, 102 database queries, 62, 73 data exchange and vocabulary, 4, 6, 7, 41-42, 52, 62, 63-65, 72, 82, 83,85-87,96, 105-107, 111, 119, 124, 125, 130, 131, 133, 135, 137, 139, 142-144, 147148, 152 federal role, 22, 23, 85-87, 111, 117 format, general, 19, 40-42, 43, 147 international, 79, 143-144 outpatient records, 19 security, 4, 6, 7, 52, 87, 119, 124, 133, 139, 142, 144-145, 147148, 152 state-level, general, 160 see also Licensure laws State governments, 6, 113, 115, 117, 125, 130-131, 133, 148, 156-179 confidentiality laws, 103-104, 164165 demonstration projects, 113, 124 licensure laws, 103, 148, 156, 157162, 173, 177-178
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From page 190... ...
, 62-63, 64-65, 111, 144 Uniform Clinical Data Set, 87, 112-113 Uniform Commercial Code, 156, 175, 177 Uniform Health-Care Information Act, 148, 166, 178 United Kingdom, 64, 78-79 Universities, 115-116 academic research, 68, 70, 106, 115 UNIX, 93 Users, 2-3, 14, 21, 26, 30-49, 99-101, 137 computer interface with, general, 43, 44, 82-83, 135 diffusion of innovations, 98, 99-101 needs, general, 2-3, 32-49 multiple, 21 patients as, 21, 39 projections, 50-54 see also Access issues; Change agents; Stakeholders Vendors, 56, 116-117, 118, 125, 141 legal issues, 105, 156-157, 158, 175-177 survey of, 91-93 Veterans Administration, see Department of Veterans Affairs Viruses, computer, 173, 178 Vocabulary control, 4, 6, 7, 41-42, 52, 62, 63-65, 72, 82, 83, 85-87, 96, 105-107, 111, 119, 124, 125, 130, 131, 133, 135, 137, 139, 142-144, 147-148, 152 Voice recognition, 62, 82-83, 87, 135, 142 w Windowing, 73, 93 Word processing, see Text processing Workstations, 44, 60-61, 135
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