-
What Are the Records and Database Issues? - Patient health information
- Patient demographic information
- Patient financial information
- Research Information
- Information about physicians, nurses, and other caregivers
- Peer review information
- Information about payers
- Business records including financial records, personnel records, practice patterns, quality assurance statistics, strategic plans, and similar information.
- Computer software
- Patient demographic information
What Might be Computerized?
- Medical records exist to: (a) facilitate patient care; (b) serve as financial and legal records; and (c)support clinical research.
- Generally, records are (a) handwritten; (b) stored in folders on shelves; (c)inaccessible for analysis; (d) not useful for decision-making.
- Problems associated with current "generation" of records:
- 1.content - missing, illegible, redundant, and inaccurate information
- 2.format - unstructured, disorganized, and improperly sorted information
- 3.access, availability, and retrieval - incorrect location, inefficient storage, and difficult information "mining"
- 4.linkages and integration - inpatient/outpatient discontinuity, non-transferability, and lack of inter-institution cooperation
- 2.format - unstructured, disorganized, and improperly sorted information
- Generally, records are (a) handwritten; (b) stored in folders on shelves; (c)inaccessible for analysis; (d) not useful for decision-making.
- A Computerized Medical Record is "computerized medical record is one that stores said information
digitally."*
- Computerization is important:
- To provide a continuum of patient care information
- Need for enhanced documentation
- Quality Management movement
- Demands of health care reform for better clinical information
- Need for data repositories
- The relative efficiency of computers in searching and retrieval operations
- Need for enhanced documentation
- Ideally computerization has as its first priority support of the clinical decision process in a manner that improves patient care quality.
- Attributes of good computerization*:
- Provides problem list
- Measures health status
- Documents clinical reasoning
- Provides linkages
- Protects from unauthorized access
- Supports continuous access
- Supports simultaneous multi-user views
- Supports other clinical resources
- Features clinical problem solving
- Supports direct data entry by physicians
- Supports management of patient care
- Provides flexibility and expansibility
- Measures health status
- Overview of Computerized Patient/Medical Records
For more information on Medical or Patient Records, see
- To provide a continuum of patient care information
Computerized Patient Records ......
- Medical Record is " medical record can be defined as a repository for information and data collected from a patient's
encounter with the health-care system."*
Once computerized, all the problems begin ....
- Clinician's Information Needs
- From Movable Type to Data Deluge
- Information Overload
- From Movable Type to Data Deluge
There are too much data and not enough information.
- What is a Data Warehouse
- Data Warehouses
The Solution to Some Problems is the Data Warehouse
- Data Mining
- Data Minefields
- Data Minefields
Data Warehouses Allow Data Mining
- Confidentiality of Computerized Records
- Confidentiality Agreements
- Information Security
- Confidentiality Agreements
Computerized records are easier to find, read and combine, so security becomes an even bigger issue.
- Informatics System from MIT
- Informatics Systems from Columbia University
- Online Medical Records Documents from University of Florida
- Informatics Systems from Columbia University
Examples of Computerized Systems
| Go to the Agenda | Go to Dr. Sauter's home page |
Page Owner: Professor Sauter (Vicki.Sauter@umsl.edu)
© Vicki L. Sauter. All rights Reserved. - Patient health information