The computerized patient record: balancing effort and benefit

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Abstract

Promise and reality: this review addresses two questions. First, why is the introduction of the computerized patient record (CPR) so slow, while its potential for improved quality of care and reduction of cost is well recognized? Second, what, in this respect, is the role of record architecture and standardization? Barriers: the impediments for CPR adoption are put in a larger context by addressing the relationship among effort, benefit, and the parties involved. An important financial impediment is insufficient return of investment. Other hurdles related to the use of CPRs are lack of integration and flexibility, which cause clinicians to experience insufficient reward to motivate them for data entry and changes in working style. Effort and benefit have to be balanced for each party involved. Requirements for improvement: lack of standardization impedes exchange and sharing of medical data, and new developments cause fear of applications to become outdated. Flexibility in content and use, integration, and adaptability to change, are key requirements for CPR systems. These requirements can most effectively be met through an architecture that separates content and structure, such that the road to standardization is not paved with frequent expensive adaptations. Strategies for implementation: successful implementation and acceptance require reliable evaluation of applications by independent professional groups. Users need to be involved in setting priorities and planning for actual implementation.

Introduction

The vision that the computerized patient record (CPR) is the technology of the future is no longer restricted to a handful of pioneers. It is a generally accepted belief that the paper record can no longer meet the demands of modern health care. Even clinicians who are not looking forward to change do understand much of the added potential of the CPR.

Despite the fact that so many healthcare professionals understand the benefits of the CPR and that the Institute of Medicine presented it as an essential technology for healthcare in 1991 [1], introduction has been slow. The CPRI monitored 225 CPR related projects over 4 years and found only nine to be successful [2]. What is impeding this introduction if the benefits are so evident? First of all, many of the benefits mentioned in the literature, are potential. Most CPR implementations meet at best part of the requirements to harvest these benefits [2], [3], which demonstrates that the effort needed to fulfill these requirements is far from trivial.

The obvious question to be asked is: are efforts and benefits balanced? Benefits are the motivation for the efforts. Hence, we need not only a deeper understanding of which efforts are needed to enjoy which benefits, but also which parties are associated with these efforts and benefits.

The paragraphs in the first section of this paper summarize the benefits, as they have been published in the literature, and we outline which efforts are required to realize each of these benefits. From there, we summarize a number of important parties involved, and we provide an overview of how these parties share in these efforts and benefits. This overview puts the expectations of CPR developments in a broader context and shows several imbalances that to our belief clarify much of the current impediments in CPR introduction. Part of these imbalances is financial: some parties do not see their financial investments returned. Other imbalances involve hurdles related to the use of CPRs, such as integration of existing data sources and physician data entry (PDE).

There is no single step solution to alleviate the problems involved in CPR introduction, but it is evident that clinicians play a crucial part in the content, quality, and usability of the CPR. Consequently, many efforts are directed toward CPRs that clinicians find attractive for consultation and data entry. In the second section of this paper we, therefore, highlight requirements for consultation and recording of data, and we discuss the relation between content and structure of patient records in view of these requirements.

Section snippets

The potential benefits of the CPR

Numerous publications explain the potential benefits of the CPR. ‘CPR’, however, is just one of the many terms for non-paper patient records, and these terms cover a wide range of definitions [2], [4], [5]. Non-paper patient records may range from scanned text to fully coded data, and range in scope from one department to a complete patient record across the borders of one institution. In this paper, we do not want to restrict ourselves to a specific definition, since one of the goals is to

Efforts required to harvest the benefits

The benefits described above come with a set of requirements. A significant portion of these requirements can roughly be divided into requirements related to consultation of records and requirements related to computer-assisted interpretation of record contents. Other requirements are more related to the barriers for actual implementation of a CPR.

The CPR for clinical use

Most early CPR systems that have found acceptance in daily clinical practice combine the advantages of on-line patient information with minimal impact on the patient–clinician encounter: data are recorded on clinical encounter forms, which contents are later transcribed and made available electronically [72], [73], [74], [75], [76]. Progress notes often remained in free text. This approach is based on the experience that clinicians are far more accepting of computer-use for consultation

Moving towards the CPR

Implementation of the CPR requires commitment of the management, whether it is a small group practice or a large healthcare institution. Hence, there are two important aspects concerning the implementation of CPRs: (1) factors that promote commitment, and (2) factors that facilitate implementation following this commitment.

One of the most important stimuli for a management to commit to the implementation of the CPR is the motivation of users. This motivation often comes from pioneers within the

Conclusions

Flexibility in content and use, integration, and adaptability to change, are key requirements for CPR systems. These requirements can most effectively be met through a common architecture and vocabulary in combination with the development of plug-and-play components. Seamless integration of functionality and content is not the only advantage. Vendors no longer need to provide total solutions, but can concentrate their resources on specific functional components. The advantage for users and

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