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Need for standards in medical communication.

E R Gabrieli

    Topics in Health Record Management
    |May 9, 1991
    PubMed
    Summary

    Clinical informatics has advanced with new tools for medical documentation. The challenge is integrating this technology while protecting patient privacy and provider confidentiality.

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    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.

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