Presentation of electronic patient data and medical audit

With the increasing use of computers to store patient data and to use these data as an electronic patient record to support the direct patient care these data now play an essential role in the care process. Such a role can be expected to expand in the years to come. It is widely recognised that such use of data for direct support of patient care increases the need for security (in particular integrity and availability). However, until now little attention has been paid to the requirements for the system from the point of view of medical audit. If the data retrieved may play an important role in the care process it is important to be able to judge whether the health care professional has acted properly in view of the electronic information that was (or could have been) at his disposal. During one of the IMIA working conferences this issue was identified. In this paper the issue is explored further. Both requirements and technical consequences are discussed.