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Computerized medical records: the need for a standard.

¹Bryn Mawr Family Practice, PA.

Journal (American Medical Record Association)

|February 8, 1990

Summary

Establishing a standard for the computerized medical record is crucial for efficient healthcare. This standard should prioritize physician and patient needs over technological limitations to ensure effective data management and reduce costs.

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Area of Science:

Medical Informatics
Health Information Technology
Clinical Documentation

Background:

The integration of technology into medical records presents challenges and opportunities for healthcare.
Effective organization, accuracy, and legibility are paramount for medical records, regardless of technological implementation.

Purpose of the Study:

To advocate for the development and adoption of a standardized format for computerized medical records.
To emphasize the importance of physician judgment in medical data manipulation and the need for technology to support, not replace, this judgment.

Main Methods:

Conceptual analysis of the core functions and design principles for computerized medical records.
Discussion of technological barriers and future considerations for medical record systems.

Main Results:

Computerized medical records should prioritize organized data storage, separating it from secondary data manipulation.
Physician judgment is essential and should be augmented, not supplanted, by software.
A machine-independent outline format and a central patient profile are proposed for textual components.

Conclusions:

Adopting a physician- and patient-centric standard for computerized medical records now will prevent future costs and interoperability issues.
Proactive standardization is key to controlling medical technology and ensuring its effective use for better patient care.
The future of medical computing is promising, provided a thoughtful approach to standardization is taken.

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