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Need for standards in medical communication.
Topics in Health Record Management
|May 9, 1991
Summary
Clinical informatics has advanced with new tools for medical documentation. The challenge is integrating this technology while protecting patient privacy and provider confidentiality.
Area of Science:
- Clinical Informatics
- Health Information Technology
Background:
- Advancements in clinical informatics have yielded new tools for healthcare documentation.
- The development of a comprehensive medical nomenclature and a prototype medical text processor signifies progress.
Purpose of the Study:
- To highlight the readiness of technology for large-scale computerization of healthcare documentation.
- To identify and address the barriers to the widespread adoption of these informatics tools.
Main Methods:
- Review of recent progress in clinical informatics.
- Assessment of technological capabilities for healthcare documentation.
Main Results:
- Two key tools, a medical nomenclature and a text processor, are now available.
- Technology is poised for the large-scale computerization of health records.
Conclusions:
- The primary obstacles to progress are the reorientation of healthcare professionals and the industry.
- The critical challenge is to balance data accessibility with the essential principles of medical data confidentiality and provider privacy.