To computerize or not to computerize the patient care record: that is the question.
The advantages and disadvantages of the Computerized Patient Record (CPR) with respect to the conventional paper medical record are discussed. The eight elements of an ideal CPR are described: (1) ability to directly capture data from all patient care sources in a variety of formats, (2) ability to assimilate and present data rapidly in a flexible and integrated fashion in all areas of the institution where patient care is provided and chart review or abstraction is done, (3) making patient safety features an intrinsic part of the CPR, (4) portability of the record, (5) appropriate privacy and security safeguards that do not restrict patient care, (6) ability to rapidly extract data for tasks that are not direct patient care activities, (7) sensible algorithms to determine what data need to become a permanent part of the CPR, and (8) the system must have exceedingly high reliability. The author concludes that improvements in patient care will be accomplished through the use of a CPR and, consequently, this technology will become the norm for the inpatient medical record within the next decade.
Elliott
Brett
B
D000465:Algorithms; D003219:Confidentiality; D006801:Humans; D008499:Medical Records; D016347:Medical Records Systems, Computerized