Still searching for the 'Holy Grail.' - computer patient record systems - includes related articles on computer-based patient record databases and assessment standards

Health Management Technology, Feb, 1995 by Richard S. Dick, James M. Gabler

The developers of three new databases propose to evaluate computer-based patient record systems in great detail. They promise to rigorously benchmark how CPR systems perform on a suite of tests in what they are calling a `CPR certification laboratory.'

The race is definitely on toward development of robust computer-based patient records, and as the vision of the potential for the CPR spreads, more companies (some coming from fields far removed from healthcare) are likely to launch efforts to establish themselves as vendors of the "leading CPR."

This rush to market by an increasing number of vendor/developers is confusing to the marketplace, especially with the level of market hype on the increase. If you think that the vendors are confused about who actually has what capability or what the status of things really is, just think about the bewildered consumers of these emerging technologies.

In the evaluation of systems, it is extremely important to distinguish among those who are shipping systems that are in actual use and are demonstrably being used by practitioners, those which have tests underway, and those with announced capabilities yet to be proven--even in test or evaluation settings.

In 1991, the National Academy of Science's Institute of Medicine (IOM) completed the most comprehensive study of clinical computing ever undertaken by the Academy. The resulting IOM report was published in the book titled "The Computer-based Patient Record: An Essential Technology for Health Care."(1) This report has become a seminal document in moving the nation toward routine use of the CPR. It identified several key concepts concerning the CPR--its definition, issues pertaining to its importance and its key attributes.

The events of the last four years have stimulated significant progress toward the development of CPRs. Substantial investments are being made by drug companies, provider organizations, investment bankers, governments and many others who share the vision that the CPR will enable. The authors believe that the CPR holds the potential to do for healthcare what the transistor has done for electronics. That is, the CPR will enable a host of capabilities the likes of which we can hardly imagine today.

Although considerable progress has been made toward CPRs, no one has yet achieved the entire vision as seen by the IOM Committee. If achieving a robust CPR were easy, it would have happened long ago; because it is not easy, it will take some time yet to achieve the lofty goal established by the IOM. After all, some have suggested that we are talking about the CPR--the "holy grail of healthcare."

The following trends have been observed as a result of examining several of the emerging computer-based patient record systems. Although notable exceptions exist to virtually each of the trends noted below, these observations and statements emanate from studies of several of the emerging CPR systems (nearly 20 systems so far). These trends are organized here to expand on each of the Institute of Medicine's 12 key CPR attributes:

1. "Problem List"

Vendors express widespread interest in supporting a problem list. Much remains to be done, however, to make this a central feature of most systems. Only a few are beginning to approach the real value associated with problem-oriented medical records. Nearly all still have to manually link information throughout the record with any particular problem.

The history of the problem's status and how it has been addressed over time is almost never addressed (e.g., the patient has had four visits associated with a particular problem; what is the status and what was done at each visit?).

2. "Measures of Health Status and Functional Levels"

Although the quest for quality has intensified, especially in terms of outcomes-based care, CPR systems are so far woefully lacking in providing some of the crucial information necessary for measuring outcomes, including the use of health-status measures and functional status of patient's health. Little appreciation for, and hence little support for, this facet of CPRs has surfaced to date. Very few I/S vendors have focused more than a token effort to address this important features.

As providers attempt to distance themselves from their competition, their need to document the quality of their organization's care will become increasingly important. Some provider organizations are attempting to install modules separate from CPRs to address this issue (especially since so little attention is being paid to it by CPR developers). This feature of CPRs will grow in importance as providers realize that documentation of quality translates into winning new contracts.

3. "Documents Clinical Reasoning and Rationale"

If properly executed, support for this feature can be facilitated and synthesized by more intelligent systems. As increased communications are required to support all members of the healthcare team, this feature takes on added significance and it becomes crucial for the continuity of care. Vendors have generally expended little effort to document clinical rationale for decisions made for care--when and why. Many vendors would likely have difficulty determining where to store such information in their CPR.