Topics in health record management最新文献

Recent progress in clinical informatics resulted in two new tools: a comprehensive medical nomenclature and a prototype medical text processor. The direction of further progress is apparent. The technology is ready for large-scale computerization of health care documentation. The new progress-limiting factors seem to be related to the reorientation of the record writers and the entire health care industry. The true challenge of the 1990s is to make clinical data readily available, without jeopardizing the cherished values of medical data confidentiality and provider privacy.

The development of the HL7 is proceeding along two lines. Much effort is being spent on solving the ambiguities of version 2.1 and in extending the standard to areas that are not yet well defined. For example, at a recent working group meeting new messages were defined for dealing with pharmacy records, specifically those relating to IVs. As the number of vendors implementing the standard and as the number of organizations using the standard increase, the standard will continue to be refined and expanded along current formats. As often as possible, these efforts will be "backwards compatible" and may be implemented by vendor choice as the need arises. These changes will be distributed as chapter updates to the current release. A parallel effort is underway that will add formality to the development of the standard. These efforts incorporate a number of case tools, including data modeling. The biggest advantage of this approach will be to reduce significantly the ambiguity in data element definitions. Completeness and correctness of data relations will be enhanced as well. New approaches to documentation, including an object-oriented specification of the data model, will increase understandability. There are still a number of domain-specific areas in which the standard needs to be defined and examples generated to show how the standard applies. Forms of data transfer other than text must be accommodated. HL7 again will take advantage of existing work in these areas, such as the work of American College of Radiology/National Equipment Manufacturers Association (ACR/NEMA) in standards relating to image transfer. HL7 will continue to move toward OSI-compatibility.(ABSTRACT TRUNCATED AT 250 WORDS)

IT offers the potential for controlling the rising costs of health care while continuing to improve the quality of health care delivery. Health care communications standards are a necessary condition to accelerating the diffusion of IT in health care. The IEEE P1157 standards, which are international in scope, are being developed by a process of open participation under the auspices of the IEEE EMBS to meet strict conformance to the ISO/OSI standards. The IEEE P1157 standards are being coordinated with related health care information systems and will make an important contribution in this area. The initial focus of the IEEE P1157 committee will provide a needed subset of the eventual standard in 1991. The long-term focus on the patient record will provide the groundwork for extension of the effort to cover communications in all of health care. Development of these standards is based upon voluntary effort. All health care professionals with an interest in this area are urged to participate actively in the process.

The computer is a valuable tool for processing information and knowledge in medicine. Its ability to store, correlate, display, and transfer vast amounts of information rapidly and economically has already greatly impacted medicine. As the standards needed to connect the diverse parts of the current systems are put into place, future capabilities will be even more significant and encompassing. With these standards will come the ability to readily draw diverse information together for appropriate display, analysis, and interpretation. Good standards are essential for the continuation of the computer revolution in medicine.

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)

Quality improvement is catching fire in the health care community, but there is much work to be done, much to learn, and much to teach. All health care professionals must remember that there are no short cuts to improving quality. American managers are so steeped in a quick-fix mentality that they resist the systematic infrastructure rebuilding described above. They scurry about fighting the same fires over and over, thinking they are doing their jobs. The truth remains that if results are to be improved, not just manipulated, then the processes that produce those results must be improved. For this to occur managers must be given the process improvement technology that separates the world class companies from those who are still wondering what hit them during the 1970s.

Recent state court decisions on access to adoption records manifest judicial lack of sympathy toward disclosure of confidential adoption information and a reluctance to abandon earlier precedents. The courts have long frowned upon any action that would potentially discourage or impede the adoption process or that would potentially hurt any of the parties involved. The state legislatures, in response to intense lobbying by adoption groups, have tempered the rigid standards of earlier laws, allowing for the creation of adoption registry services in 21 states and for independent searches for biological parents to solicit their consent in 9 states. Still, only 3 states give an absolute right of inspection, while 18 require a court order before access to records will be allowed. Medical records practitioners should determine the rules applicable to the medical records of adoptees in their states. In the absence of specific court or statutory authority permitting the release of such records or of the consent of the natural parents, practitioners should refuse access to these records.