Standards for automated patient records.

Abstract

The work in standards development is essential to the rapid development of automated patient records. The standards set forth the common pathways needed to support and strengthen parallel efforts in automation throughout medicine. Automation fosters a changing paradigm in patient records. Automated records will not only provide more timely, accessible patient information, but will provide opportunities to link practitioners to knowledge systems, thereby supporting the diagnostic process and quality indicators that generate clinical interventions and reminders. A dynamic, complete patient record consistently maintained across diverse care sites will continue to be an essential component in patient care. Standards for the information content, vocabulary, and linkage between systems will provide the foundations for patient care information systems. Because the individual patient record uniquely represents the patient, these systems will advocate more completely for individual patients and support practitioners' decision making on their behalf. As expressed by Waters and Murphy, "We can describe a patient in many ways, according to many needs, according to many characteristics, yet in so doing we will inevitably compile a set of information inseparable from a particular individual." That concept is unchanging. Technology supported by accepted standards ensures that patients can be served through effective, timely, complete information. In serving the patient, the health care system can be served. In an article in Decisions in Decision Economics Dr. Paul Lang explained that Successful management, that is, the acquisition, collation, organization, storage and retrieval of patient-related information, is not only essential to an acceptable future for the health care-system, but is also critical to surviving the crisis of the present.(ABSTRACT TRUNCATED AT 250 WORDS)