Introduction
The need to share patient-identifiable information (PII) among
organizations has lead to attempts at the creation of a computerized Patient Record
(CPR). This record can be viewed as the repository of clinical
information for that patient. CPR holds great potential for improving health
care. CPRs enable real-time review of diagnoses and care plans to ensure that
established standards of care are being met. Properly implemented, this has
the potential of reducing the variability in care and enhance the quality the
health care decision process (National Science Council, 1997).
It is assumed that patient-identifiable information can be obtained across
organizations by linking a unique patient numbers with their CPR's. However, the ability to obtain this information easily, has caused real concerns
among various interested groups. In a way,
this ability to access information easily is making it more difficult to access information.
Concerns regarding unauthorized access, legal liability, privacy, security
and a host of other issues have giving rise to a number of methods to
curtail the sharing of information. In many cases, specific agreements have
been established to limit data sharing among affiliated companies (National
Research Council, 1997).
In the US, the Health Insurance Portability and Accountability Act of 1996
directed the Secretary of Health and Human Services to promulgate security
standards for electronic health information.
Advantages
The
National Research Council (1997) summarizes the advantages of the CPR by saying
"Electronic
health records can manipulated by computer-based tools, so that knowledge
about standards of care can be used to generate alerts, warnings, and
suggestions. These types of capabilities are known variously as real-time
quality assurance, decision support systems, critiquing engines, and event
monitors. Such capabilities may be useful in reducing some of the disparity
between the amount and the quality of care delivered to different individuals.
Electronic records also hold the promise of improving clinical research. Today
most information about the effectiveness of tests or treatments, if in health
records at all, lies buried in large stores of paper files that cannot be
analyzed economically."
In
partially,
-
Enables
real time review of patient historical data
-
Enables
real time review of diagnoses
-
Enables
real time review of procedures
-
Enables
real time review of outcomes
Requirements
In the past, a strict data model was required before an application or data
model could be designed. Before the application could access the data storage,
it was required that the data structures be known. Today, this is not
required. Today's relational databases use SQL for common communication. It is
not necessary that the application know where or how the data is physically
structure.
The Standardized "Structure of the Computerized Patient Record"
is not a requirement. Relational databases allows changes in both physical
structure and the addition of data fields without having to change the
underlying applications. Reports can be designed "on the fly."
User Friendly
Patient Identification
The only way that data can be analyzed is by having patient-identifiable
information.
Standards
Business and Legal Issues
The issue of who owns the patient data and what rights
and responsibly they have to this data is the major issue in sharing
information. I said "sharing" not developing a computerized patient
record. If an organization has no reason to share information, then the
organization has no reason to spend the time and effort to develop standards.
It has been pointed out, and rightly so, that in order for a project to succeed
the chief executive of the organization must be enlisted. Chief executives are
generally very astute business people and they know that there is nothing in
it for them to share their data.
Although security, privacy, and confidentiality are
listed as the major reasons for the failure to implementation a CPR, surveys
show that security of the system is still not considered a major
issue among health care organizations (security book). Their real concern is losing the
competitive advantage that this information gives to them. Since many of these
"business" organizations sell their products just as any other
business, maintaining their profit margins is very important. During the
decade after DRG's were introduced many hospitals failed. These hospitals that
did not survive were unable to operate like a business. Today, the hospital
that can attract the most customers with good service at fair prices wins the
rewards.
Even researchers and project leaders refuse to share
their data because of a desire to compete.
Data Entry
In order for data to be converted into information it has to be structured
into a form that is readily understandable by an application and it has to be
coded into a form that is understandable by the user of the system.
To accomplish this, three different approaches have been proposed
(Institute of Medicine, 1997):
- natural language processing
- structured data entry.
- form-driven data entry
Natural language processing is based on an application that automatically
extracts coded medical data from free text. It has been stated that one of the
advantages of this system is that the health care worker does not have to
alter the way in which they work. However, this is actually a disadvantage.
The system, as to be develop, should reduce the amount of work that a health
care worker needs to perform to collect information. Before a system can
automatically extract code data, it must be "trained" in the
vocabulary of the health care worker, i.e. the health care workers vocabulary
must be mapped to a standard. For this to happen, each and every health worker
must work with the natural language processor in order for it to learn which
words go with which codes. Since the medical worker himself does not write in
the same way, natural language processing is prone to errors.
Structured Data Entry is context sensitive and is adaptable to different
users. It consists of forms who's content is knowledge drive. In a structured
data entry-oriented system, the forms are structured but their contents can
continuously be adapted to the user. The knowledge base keeps track of the
individual user's expressions and will map this language to a standard
(Institute of Medicine, 1997). Again, the disadvantages of this system is the
same as natural language processing.
Form-driven data entry is based on the health care worker
filling out a pre-designed form. The data is highly structured, has a
predefined vocabulary, and pre-coded. Healthcare Professionals can quickly use
forms to input their data, it can prevents errors, and ensure that important
data is not missing. Forms can be easily designed for each type of process and
can be designed to correspond to "evidence bases protocols." For
instance, a form can be designed to capture all the relevant information of a
heart attach patient. If important data is missing from the this form, alerts
can be issued. Data from standardized forms easily enables comparisons among
Healthcare Professionals and patients. Space on the form can be designed for
free text input for notes and that can be "text indexed" for retrieval
Patient Identification
Must discussion has been built around the development of a unique patient identification
number
Patient Identification across venues
National Health Care system identifying number
Development of either a new identifying number or the use of an already
assigned number such as the U.S. Social Security number.
Smart Cards
The German project Diabcard, uses smart cards for the storage and change of
data for patients suffering from diabetes (Institute of Medicine, 1997)
Methods at Standardization of Data Exchange
There have been many attempts at standardization of the
data exchange between medical systems. These attempts can be divided into three different methods (Grimson,
Grimson, and Hasselbring, 2000)
Message-Based
HL7
Was founded in 1987 and is an American National
Standards Institute (ANSI) accredited Standards Development Organization (SDO).
Security
Better security because it is easier to monitor access than with paper.
Privacy (see
Security
- Privacy)
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