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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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4
The Road to CPR Implementation

Technological change is a complex process that is influenced by a multitude of factors, including the attributes of a technology, the users of the technology, and the environment in which the technology is used. Successful implementation of computer-based patient record systems depends on ''more than the transmission of technical details and the availability of systems" (Anderson and Jay, 1987:4). It requires an understanding of the factors that influence the development and adoption of computer technologies in health care.

This chapter first identifies the factors that could enhance or impede CPR development and use. It then presents the committee's plan for addressing these factors. The plan includes a discussion of the various organizations that have a role to play in CPR development and diffusion, the types of activities that would facilitate patient record development, how such activities might be implemented, and when such activities should take place. Chapter 5 presents the committee's formal recommendations for achieving the primary goals of the plan.

Development and Diffusion Factors

The process of technological change involves two general stages: development and diffusion. Development is the production of new capabilities or the alteration of characteristics of existing technologies; diffusion is the application of a new technology in the provision of services. These two stages do not necessarily occur in chronological sequence. User application can reveal that a technology needs further development. Alternatively,

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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diffusion sometimes parallels the development of a new technology (NAS, 1979). Moreover, as discussed below, the factors affecting development and diffusion are interrelated: development is unlikely to occur if the conditions for diffusion are unfavorable.

Barriers to Development

Patient Record Definition

A basic impediment to the development of CPRs and CPR systems has been the lack of a clear definition of what a CPR could and should be. An intellectual understanding of what a CPR needs to do, the range of individuals for whom it needs to function, and the expectations and performance demands of its users is an essential prerequisite to successful design of a CPR system (Teach and Shortliffe, 1981). Many computer-based information management systems are currently in place and generate and use patient data for various purposes (e.g., billing, laboratory, radiology); what is lacking is a unified concept of what constitutes a computer-based patient record system.

A fully articulated definition of a CPR and CPR system should describe attributes of the record and system (i.e., content, format, and function) as a guide for system developers and users.1 It should not, however, prescribe how those attributes are to be achieved. Resolution of that question is best left to CPR system developers and vendors.

Chapter 2 identifies basic CPR system requirements, but system designers require more detailed specification in certain areas. Among these are the level of performance (e.g., speed and convenience) the system must provide to achieve health care provider acceptance; the kinds of new system functions needed to justify a change in current routines of record use and the costs of implementation; the frequency with which multiple users would view the record simultaneously; the level of system security, confidentiality, and reliability required; and the level of institutional, regional, national, or international interconnectivity demanded of the system.

In particular, patient record system developers require specific information about system functionality and performance to design systems that meet user needs. Understanding the diverse set of CPR user needs requires that representatives of all users be involved in a process of setting priorities for system functionality and performance.

1  

As discussed in Chapter 1, the committee's definition of a CPR is an electronic patient record that resides in a system specifically designed to support users through the availability of complete, accurate patient data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×
Content and Format Standards

As discussed in Chapter 3, CPR development has been, and continues to be, impeded by the lack of standards for the content and format of CPR data (McDonald and Hammond, 1989; Bradbury, 1990; Gabrieli and Murphy, 1990; Lindberg and Humphreys, 1990; Masys, 1990). To exploit the potential benefits of linking CPRs across specialties and institutions, developers must ensure the following. (1) The content of CPRs must be defined; that is, each CPR should contain a uniform core set of data elements. (2) Data elements must be named consistently; that is, some form of vocabulary control must be in place. (3) Format standards for data exchange must be developed and used.

Defining a core set of data elements requires participation by representatives of all patient record user groups. (Exclusion of any group could diminish the efficiency to be gained from implementing CPR systems if, as a result, key data elements are excluded from the core data set.) However, the uniform core data set should not be so large that it requires health care professionals to collect information that does not derive directly from routine service provision. Moreover, because providers are likely to require data elements in addition to those in the uniform core data set, CPR systems should be flexible and not be limited to core data elements.

Vocabulary control efforts have already led to substantial progress in developing standardized vocabularies. The use of existing controlled vocabularies in combination could cover the basic name of each patient problem and of each procedure performed by a practitioner (Lindberg and Humphreys, 1990). Inadequate support for the timely update of clinical vocabularies, however, remains an obstacle to developing better vocabulary control for the CPR. Another obstacle is user resistance: users generally have not considered the benefits of a reasonably specific, controlled vocabulary as warranting a switch to a new system—especially if that system entails higher costs for record creation and maintenance (Lindberg and Humphreys, 1990).

Existing format standards focus on particular portions of the record; no single format standard exists that could be used for the entire CPR. Nor is there at present a means for establishing one standard for use by the entire health care industry. In short, format standards for data exchange need further development and a means of achieving credibility. To date, such efforts have been carried out primarily by volunteer organizations. Greater support (i.e., funding and recognition) of these efforts would help to accelerate standards development.

Costs and Risks

Venture capital is unlikely to be forthcoming for large-scale technological systems that require sizable investments before yielding a return in a

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

highly uncertain market (NAS, 1979). Consequently, development of a technology may require subsidization of development costs or creation of a more certain market, or both (NAS, 1979). Both of these factors apply to CPR systems: they require significant investment for development, and a high degree of uncertainty exists regarding the willingness of health care providers to purchase the systems.

As discussed in Chapter 3, the committee found no comprehensive CPR systems in existence in 1990. Furthermore, no cost data are available on the monetary investment that might be required to implement such a system; evaluations of cost data related to computer applications tend to have focused on medical information systems (MISs) rather than on CPR systems. MIS development costs and time estimates, however, do convey a sense of the magnitude of CPR development costs and time. A survey of automated ambulatory care systems found that development costs ranged from $100,000 to $10 million and that development time ranged from 1 to 7 years (Henley and Wiederhold, 1975). Congress's Office of Technology Assessment (OTA) has estimated the development cost for a commercial inpatient MIS to be $25 million and the time to develop such a system to be 10 years (OTA, 1977). Costs related to the acquisition of a technology are discussed later in this chapter.

A General Accounting Office (GAO) study on the use of information technology in hospitals found that commercial hospital information systems currently in use were not as comprehensive as those planned by the Department of Defense and the Department of Veterans Affairs (GAO, 1988). The GAO cited two factors that could account for the less extensive development of commercial information systems—which may itself reflect an uncertain market. The first is the potentially small market for such systems.2 The second is the low level of spending for automation in the hospital industry. The causes of this low level are uncertain, but GAO offers several possibilities: the historical lack of incentives for hospitals to minimize costs (a situation that has changed since the implementation of the prospective payment system by Medicare); the difficulties hospitals face in trying to raise initial funds for information systems; the cost savings in early systems were attributed to reductions in the work of clerical rather than clinical staff; the difficulties involved in achieving or quantifying savings (time savings in particular are likely to be fragmented); and resistance by medical personnel to the introduction of information management technology (GAO, 1987).

2  

Some experts believe hospitals must have 200 or more operating beds to make optimal use of hospital information systems. According to the GAO report (1988), nearly 70 percent of community hospitals have fewer than 200 operating beds.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

The CPR market may also be uncertain because computer applications are generally not well understood by health care practitioners (Anderson and Jay, 1987). This lack of understanding limits the demand for such products and, as a result, reduces commercial interest in developing new products. Few sources exist to help practitioners learn what a computer technology can do for them, and there is little likelihood such help will be forthcoming in the near future, given the costs associated with producing such resources.

Barriers to Diffusion

Technological diffusion has been analyzed in greater depth than technological development. Rogers (1987) presents five characteristics of a technology that influence its adoption:

  • relative advantage over existing technologies (the degree to which an innovation is perceived as better than the practice it supersedes);
  • compatibility (the degree to which an innovation is perceived to be consistent with values, experiences, and needs of potential adopters, as well as with the structure of adopting organizations);
  • complexity (the degree to which an innovation is perceived as difficult to understand and use);
  • feasibility3 (the degree to which one can experiment with an innovation on a limited basis); and
  • observability (the degree to which the results of an innovation are observable to others).

Other factors also affect CPR adoption and use, including the environment of the health care system; leadership; user behavior, education, and training; costs; social and legal issues; and network needs. Major concerns in these areas are briefly noted below.

Environment of the Health Care System

The U.S. health care system has been characterized as comprising "thousands of relatively autonomous units, centering on large hospitals, which are themselves made up of relatively autonomous divisions and departments" (Lindberg, 1979:215). Maintaining CPRs, however, "imposes requirements for greater coordination among separate ancillary services, particularly with regard to terminology" (McDonald and Tierney, 1988:3438).

3  

Rogers (1987) uses the term trialability to reflect the degree to which an innovation can be experimented with on a limited basis.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

By extension, the use of patient records that are linkable requires coordination among the institutions that are likely to contribute to or use such records. Thus, autonomy within and among provider institutions must be addressed when planning and implementing CPR systems.

Disaggregation of care (i.e., the delivery of medical care by many small providers who operate independently of and in competition with one another) has significant implications for the adoption of a coordinative, systemwide technology. Such technology is often subject to nonadditive benefits—that is, the benefits of collaboration among multiple providers outweigh the benefits of individual adoption. As a result, providers have fewer incentives to acquire such technology (NAS, 1979).

The reimbursement policies that are applied to providers influence their willingness and ability to acquire CPR technology. For instance, under cost-based reimbursement schemes, providers have more incentive to acquire technologies that are reimbursable than technologies that are not reimbursable. In contrast, prospective payment systems create incentives for institutions to reduce costs—and thus to acquire potentially cost-reducing technologies such as CPR systems. Under current reimbursement policies, any potential acquisition of new technology must contribute to the improvement of a provider's financial status or at least be budget neutral. It should also substantially improve patient care processes, for example, by providing clinical decision support or by giving complete record access to authorized personnel.

Leadership

Given the fragmented environment of the U.S. health care system, it is not surprising that at present no one organization or agency is leading the effort to establish the necessary infrastructure for national implementation of CPRs and CPR systems. National and regional organizations may be knowledgeable about the issues, but they are not consistently soliciting information from or educating their members about CPRs. Thus, despite the many aspects of CPRs that are in need of coordination, no organization has the operational responsibility and funds to establish programs and projects to set the direction for the health care industry. Overcoming this problem could be the key requirement for progress, and the committee devoted considerable attention to discussing and formulating its primary recommendation in this area (see Chapter 5).

User Behavior, Education, and Training

Users are more likely to accept a technology if several conditions are met: they have a stake in the system; they can use it at minimum cost; the

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

technology produces information leading to improved clinical services; that information is almost immediately available; and the technology increases their status (Young, 1987). Computing applications that do not significantly change the routines associated with the practice of medicine are also more likely to be accepted by users (Kaplan, 1987).

An individual's propensity to use a technology has been attributed to specialization, fear of malpractice suits, industry promotion, a specific form of medical practice, and payment methods (Banta, 1987). An encounter with a peer who is already using a technology can also influence an individual's use (Anderson et al., 1987).

Young (1987:9) suggests that problems with the acceptance of clinical computing systems relate to the way a physician organizes his or her thought processes and interacts with written aids.

[U]se of the medical records is not properly appreciated. The written record is not just a repository of information; it often forms part of the doctor's thought process, so that the style of writing, the position on the paper of particular items, abbreviations, the sequence of information, use of margins, may all have an important significance for the individual practitioner—a significance which goes beyond the actual facts recorded, and which is impossible to capture in an orderly typed record or video display unit. It is the loss of these individual aspects of the medical record which causes most problems. The advantages of structured, typewritten reports commonly do not outweigh the loss of the extra information which is conveyed to the individual practitioner by the above features.

Some individuals in the health care community are skeptical that computer systems can be designed to meet user performance and functional requirements. They may also doubt that a CPR system will improve an institution's ability to manage its information. Previous negative experiences with computer systems or inaccurate data generated by a system may cause some providers to actively resist the acquisition and implementation of CPRs. Whether or not an individual clinician is skeptical about a CPR system, using it will require behavioral changes. Thus, as noted earlier, some natural resistance to the CPR is to be expected.

Individual institutions will need educational programs to support these changes. Educational curricula for health care professionals must also be modified to reflect the role of the CPR in the provision of health care services. Who will develop, implement, and pay for such materials (e.g., vendors or professional groups) is an area of considerable uncertainty.

CPR implementation requires experts who can support CPR users, but at present only a relatively small number of individuals have the necessary expertise in medical informatics (Clepper, 1991). More people must be encouraged to enter this field and a variety of educational and training

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

programs tailored to different types of health care professionals must be developed. The committee considered the educational barrier to CPR development sufficiently important to formulate a specific recommendation to address it, as discussed in Chapter 5.

In addition to education, practitioners need incentives to use CPRs to enter data and maintain patient records. Perhaps the greatest motivation for practitioners to use CPRs would be to produce evidence that CPRs can help to improve the quality of patient care and reduce the administrative burdens they currently face. As discussed in Chapter 3, at least one institution has experimented with a fee-for-data arrangement for physicians who input their own discharge summaries into an automated system. Other arrangements to encourage the use of CPRs are also feasible. For example, third-party payers could provide incentives for health care providers (including physicians) to submit claims electronically or in a computer-compatible format (e.g., diskette). Alternatively, third-party payers may reject reimbursement claims that do not contain standard data. A regulatory approach is another possibility for use in place of or in addition to an incentive structure. However, the potential side effects and costs of both incentives and constrictive regulations must be understood and carefully weighed.

Costs

A major factor influencing a firm's adoption of a technology is the size of the investment required relative to the size of the firm. Acquisition costs for CPR systems are likely to be substantial but are difficult to estimate.4 This difficulty arises because the purchase or lease price of a system does not reflect the total implementation cost; it excludes the cost of training and potential losses of productivity during transition to the system. Studies that have attempted to estimate total costs have tended to focus on MISs rather than CPR systems. Further, purchase or lease prices for CPR systems vary significantly, depending on the scope of functions a system offers, the size of an institution, and an institution's previous level of automation.

One cost analysis of the implementation and operation of an automated ambulatory care medical record system found that the cost per patient encounter of a computer-based system was 26 percent greater than the direct costs associated with operation of a manual system. However, the manual system failed to access 18 percent of the records requested within the demand

4  

A confidential survey of CPR vendors conducted by the Technology Subcommittee of this IOM study committee revealed that purchase or lease costs for a CPR system range from $2 million to $6 million for a medium-sized hospital (see the appendix to Chapter 3).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

time, whereas the automated system provided access to 100 percent of the records requested. Quantification of the access benefit reduced the difference in costs between the two systems (Koster et al., 1987).

This cost analysis illustrates another major difficulty faced by health care provider institutions deciding on acquisition of a CPR system. Decisions about whether to acquire technology are based in part on information about the benefits of the technology; once again, data on CPR system benefits are sparse. Few recent studies have analyzed actual costs and benefits. The studies that have been conducted address MISs rather than CPR systems; they also focus on projected rather than actual experience or include only those benefits that can be measured in terms of dollars and exclude such benefits as improved quality of care or reduced waiting time for patients.

The costs of acquiring and operating CPRs and CPR systems will be borne primarily by practitioners and health care provider institutions. Yet the benefits of these systems will accrue to patients, practitioners, health care provider institutions, third-party payers, researchers, policymakers, and the public. These cumulative benefits of CPR systems should exceed the benefits individual practitioners and health care providers might be expected to gain. As such, CPR systems in certain respects represent a public good.

Given today's strict budget constraints, health care provider institutions (including physicians' offices) must choose among alternative technologies when allocating resources. Compared with a CPR system, other technologies could offer greater monetary benefits to an individual institution, albeit lower combined or social (public good) benefits. When this situation prevails, provider institutions have fewer incentives to invest in CPRs and CPR systems.

Nonclinical data users (e.g., third-party payers and researchers) could also incur costs from CPR implementation. They may need to modify existing systems or acquire new ones to be compatible with CPR standards; they may also need to revise procedures for handling computer-based data and develop training programs for personnel.

The cost of CPR technology, like the cost of computer technology in general, may well decrease over time. Moreover, CPRs may reduce the costs of care enough to offset the expense of acquiring and operating CPR systems, although this remains to be proved. The committee was quite concerned about the immediate barriers to CPR implementation raised by potentially substantial costs for full acquisition, installation, and operation of CPR systems across the nation; it was also concerned about the distribution of these costs. Consequently, it formulated a specific recommendation to address these matters, which is presented in Chapter 5.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×
Legal and Social Issues

The legal and social issues involved in implementing CPRs and CPR systems are formidable. State licensure requirements for hospital medical records are obsolete, ambiguous, and nonuniform (Waller, in this volume). The wide variation among states in hospital licensure requirements for medical records makes it difficult to develop CPR systems that comply with licensure laws in all 50 states; this factor in turn hinders the development of CPR formats that can be used nationally. Failure by a vendor to establish a CPR system's compliance with one or more state licensure requirements may adversely affect the system's marketability. The differences across states could be so great as to make national implementation impossible.

Hospital licensure laws and regulations in some states still assume a paper patient record, which makes the legal status of CPR systems unclear. Other state laws and regulations appear to permit use of some forms of automation but not others, or the use of automation for some, but not all, patient record functions. It is not clear whether regulations requiring that records be kept in ink or be typewritten permit the creation of records electronically or the use of lasers. Further, the regulations in many states require that medical records be signed but are silent on whether a computer key or code can be substituted for a signature.

Issues of record ownership, responsibility, and control must also be addressed. The physical records are the property of the provider institution at which they were created. In addition, provider institutions currently are responsible for ensuring the accuracy and completeness of record contents (Amatayakul and Wogan, 1989). As data are transmitted and shared among institutions, all with the ability to add and update information from variety of settings, the principles of ownership become blurred. It is not clear who would maintain records for routine use and maintain the structure of the record to accommodate new terminology and data elements for new diseases, treatments, tests, and approaches to health care. The locus of control of access to patient data is another unanswered question. Current laws concerning disclosure of and access to patient record information vary from state to state, further complicating the transfer of patient information across state lines.

Perhaps the impediment to CPRs that is of greatest concern is the issue of privacy. The computerization of most types of record keeping, as well as the recent well-publicized cases of inappropriate access by computer hackers, has increased concerns about the misuse of personal information (Westin, 1976; Privacy Protection Study Commission, 1977; Peck, 1984; Agranoff, 1989). A system in which patient data, including sensitive information (e.g., human immunodeficiency virus test results, data on psychiatric treatment),

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

can be accessed more easily may be strongly resisted in some quarters. 5

There are several aspects to concerns about confidentiality of information and patient privacy. Ultimate responsibility for protecting the privacy of patient data that are shared among multiple users has not been defined; in addition, generally accepted standards for the protection of computer-based data do not exist (Agranoff, 1989; NRC, 1991). The consequences for breaches of confidentiality vary by state and in some cases need to be stronger than they are at present (Waller, in this volume). The National Conference of Commissioners on Uniform State laws drafted the Uniform Health-Care Information Act to address issues of patient privacy, patient access, disclosure of patient information to third parties, and transfer of such information across state lines (National Conference of Commissioners on Uniform State Laws, 1986). As of this writing, however, only one state had adopted this act (Waller, in this volume).

Concerns about patient privacy affect more than the security features of CPR systems and legal remedies. A consistent personal identification number (PIN) in all patient records would facilitate record linkage across time and provider institutions (National Center for Health Statistics, 1990; Washington Business Group on Health, 1989). Nevertheless, despite its operational attractiveness to researchers and other patient record users, the PIN raises concerns about the increased potential to invade patient privacy (Washington Business Group on Health, 1989).

Currently, the Food and Drug Administration (FDA) device regulations and authorities do not apply to computer products intended only for use

5  

Westin's 1976 study of the impact on citizen rights of computers in the health care field found that ''most cases of actual harm involving individuals were still arising from manual records" and concluded that the main problem with the use of computer-based patient records involved "potential harm—the creation of health data systems that many health professionals, citizen groups, and individuals directly affected by such systems consider to be threats to basic rights" (Westin, 1976:xvi, emphasis in original). As noted by Lindberg (1970), however, the public and its elected legislators must have their anxieties allayed about potential misuses of data.

Some observers have suggested that computer-based patient record systems will offer greater confidentiality for patient information because they can limit the information that various users can see. For example, administrative or financial personnel could be prevented from seeing sensitive diagnostic or treatment data. Further, CPR systems could provide an audit trail listing those personnel who accessed a particular record (Hard, 1990).

As discussed in Chapter 3, however, existing security technology frequently has been not applied to current CPR systems. Moreover, a recent National Research Council (NRC) study on computer system security concerns concluded that several trends reflected a growing potential for system abuse. Among these trends are the proliferation of networking and embedded systems, the widespread use of databases containing personal information, and the widespread ability to use and abuse computers (NRC, 1991).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

in such traditional library functions as storage, retrieval, and dissemination of medical information (Food and Drug Administration, 1989). As of this writing, however, the FDA's policy on the regulation of computer products had not been finalized; this situation creates uncertainty for vendors about potential regulation and its effects on system development costs and time.

Liability for system defects is also a concern of vendors, particularly given the still-developing field of medical computer liability (Brannigan and Dayhoff, 1986; Willick, 1986; Metzger, 1988; Denis and Poullet, 1990). It has been asserted that a strict liability is likely to be applied to system vendors in cases in which the computer produces output on which a physician relies without further checking, for example, patient record systems (Brannigan and Dayhoff, 1986; Bronzino et al., 1990).

Liability for defects in clinical decision support systems is less clearly defined. System developers (i.e., health care specialists and computer programmers), manufacturers, purchasers, and users are all involved in bringing a computer system to the patient. In cases in which harm is caused, liability could be assigned if negligence (i.e., lack of due care) can be proved and if the patient can prove that the negligent party owed a duty of care to the patient. (Physicians already have an established duty of care to patients.) Practitioners are expected to use such systems to supplement the medical library or to act in place of a consultant; they can ignore information provided by such systems and are expected to evaluate its accuracy. Thus, liability for negligence in the use of clinical decision support systems could apply to practitioners.6

The nature and obduracy of the legal barriers to CPR implementation must be understood, underscored, and addressed. For that reason, Appendix B discusses legal aspects of computer-based patient records and record systems. Among the more critical legal aspects addressed there are regulatory and accreditation issues, evidentiary issues, patient privacy and record access concerns, record ownership questions, legal risks attached to specific CPR systems, and computer contracting issues. The committee regarded these issues as significant obstacles and formulated a specific recommendation to address legal barriers (see Chapter 5).

Network Needs

To transmit and link records presumes the existence of an infrastructure, that is, a network and standards for data communication on the network.

6  

There has also been some discussion about the potential for practitioners to be found negligent if they do not use clinical decision support systems once the systems become widely available in the future (Willick, 1986; Metzger, 1988).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

Both communications technology and a management structure to coordinate participants are necessary elements of a network. Currently, the necessary coordinative mechanisms and the resources to establish and operate a health care computer network are not available. Those in the health care field must, as a result, look to other established networks for data transmission.

Internet is a loosely organized confederation of federal, regional, and local networks that are used by researchers and educators for electronic mail, software and data file transfer, graphics and image file transfer, remote computer access to supercomputers and other specialized research instruments, and remote access to computerized databases.7 An estimated 1 million researchers are active users of the academic networks that are connected to Internet. It does not, however, provide users with uniformity in the type and quality of service; furthermore, despite its size, Internet does not yet reach the entire research and education community (Gould, 1990a).

Federal sponsors and academic participants envision continued evolution of Internet until it becomes a user-friendly, unified high-speed research network with nationwide coverage. The Federal Networking Council8 plans to transform Internet into a full-fledged National Research and Education Network (NREN) in three phases. The final phase calls for an operational national network with gigabit-capacity trunks and for transition of the network from government to commercial operation (Gould, 1990b).

The NREN is being built to support "communication and resource sharing among institutions and individuals engaged in unclassified research and scholarly pursuit" (Gould, 1990b:1). As such, it is a model for the kind of infrastructure needed to transmit patient record data routinely. Given the

7  

In 1969 the Defense Advanced Research Projects Agency (DARPA) established an experimental network to demonstrate the potential of computer networking based on packet-switching technology, which allows many users to share a common communications channel. During the 1970s, DARPA sponsored several additional networks and supported the development of a set of rules and procedures (called the Internet protocols) for addressing and routing messages across separate networks. In the 1980s, DARPA sought to separate the operational traffic and administrative burden of military research and development (MILNET) from that of general academic research needs (Internet). Since 1985, the National Science Foundation has been responsible for coordinating the development of Internet. Funding for operations comes from five federal agencies involved in operating research networks and from universities, states, and private companies that operate and participate in local and regional networks (Gould, 1990a).

8  

The Federal Networking Council includes representatives from DARPA, the Departments of Energy and Health and Human Services, the National Aeronautics and Space Administration, and the National Science Foundation (Gould, 1990a).

9  

Senate Bill S. 1067 (High-Performance Computing Act of 1990) authorized the expenditure of $95 million over three years by the National Science Foundation for research, development, and support of the National Research and Education Network (National Science Foundation, 1990).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

magnitude of the resources required to establish a national network,9 the committee recognized the utility of using the NREN to accommodate the data transmission needs of health care beyond simply research and education. The committee viewed planning for health care's high-speed network needs to be a key factor in CPR diffusion and proposes a specific approach for future efforts later in this chapter.

Elements of an Implementation Strategy

The remainder of this chapter outlines the elements of a strategy to foster nationwide implementation of CPRs and CPR systems within a decade. The discussion focuses first on change agents and stakeholders, moving on to resources and finally organizational structures. Specific committee recommendations directed toward particular aspects of this strategy are developed more fully in Chapter 5.

Change Agents and Stakeholders

The committee distinguished between potential change agents and stakeholders in the process of developing and implementing CPR systems. Change agents are individuals or organizations who have, first, a mandate related to or significant interest in CPR implementation and, second, the resources or means for effecting a change (e.g., leadership position, regulation, funding). Change agents are in a position to initiate and facilitate the change process.

Stakeholders are individuals or organizations who are affected positively or negatively (or both) by the change and who thus may support or oppose it accordingly. Potential impacts faced by stakeholders include, for example, financial gain or loss, a threat to professional autonomy, and an increased risk of loss of privacy. Although stakeholders may not initiate a change process or have the potential to advance a desired change, they may have the ability to thwart it.

Table 4-1 identifies the main organizations and groups of individuals who are potential change agents or stakeholders with respect to developing and implementing CPR systems. They are grouped by sector—public or private—and are further designated according to the scope of their primary influence (i.e., national, regional, local, or individual).

To engage the support of change agents in the change process, it is necessary to understand their interest level and available resources. To manage the change process, it is necessary to identify the potential impact of a change on stakeholders. The interests and resources of major CPR change agents and the potential impact on CPR stakeholders of the changes they might effect are discussed below.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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TABLE 4-1 Change Agents and Stakeholders Important to the Implementation of Computer-based Patient Record Systems

Organization

Change Agent/Scope of Influence

Stakeholder

Public Sector

 

 

Agency for Health Care Policy and Research

Yes/national

Yes

Centers for Disease Control

No

Yes

Congress

Yes/national

Yes

Department of Defense

Yes/national

Yes

Department of Veterans Affairs

Yes/national

Yes

Food and Drug Administration

No

Yes

Health Resources and Services Administration

Yes/national

Yes

Health Care Financing

Yes/national

Administration

Yes

National Institutes of Health

No

Yes

National Library of Medicinea

Yes/national

No

State health agencies

Yes/regional

Yes

State legislatures

Yes/regional

Yes

Private Sector

 

 

Computer standards organizations

Yes/national

No

Computer-based patient record vendors

Yes/national

Yes

Health care professionals

Yes/individual

Yes

Joint Commission for Accreditation of Healthcare Organizations

Yes/national

No

Patients

No

Yes

Patient groups

Yes/local to national

Yes

Professional associations

Yes/national

Yes

Professional schools

Yes/regional to national

Yes

Provider institutions

Yes/local

Yes

Researchers

No

Yes

Third-party payers

Yes/local to national

Yes

Universities

Yes/regional to national

Yes

a A specific agency of the National Institutes of Health.

Health Care Professionals and Professional Associations

Health care professionals bear a dual burden: they must learn to use a new technology, and they must change their behavior. Some professionals may view the CPR as a threat to their professional roles and resist implementation of CPR systems through attempts at circumvention or even system sabotage (Dowling, 1987). Alternatively, professionals can support

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

development and implementation by participating in planning and by influencing their peers.

Professional associations for physicians, nurses, dentists, social workers, physical therapists, and similar kinds of health care practitioners are all vehicles by which to provide ongoing education to their members about the benefits and liabilities of CPRs. Associations such as the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, American Medical Record Association, American Nurses Association, and Group Health Association of America are among the societies that could implement formal CPR education and awareness programs as part of their membership mailings and annual meetings. Many already have active committees to deal with medical informatics issues.

These and similar associations are likely to voice the concerns of their members, but they are also in a position to influence their members. Depending on how they weigh the advantages and disadvantages of CPR activities, they can lobby for or against them. To the extent that professional organizations see more benefits than liabilities in CPR implementation, they can be valuable participants in future consensus-building activities.

Patients and Representatives of Patients

As discussed earlier, the question of ensuring privacy and confidentiality has been identified as one of the crucial hurdles to effective CPR implementation. Given patient concerns about privacy and the potential for CPR systems to increase information flow within and outside of health care provider settings, patients may distrust CPR systems. Furthermore, patients are no more likely than health care professionals to use or understand computers, let alone computer-based record systems.

Survey data suggest that Americans view the nation's health care system as poorly organized and inefficient; most believe that rising health care costs can be reduced without cutting the quality of care (Blendon, 1988). As noted elsewhere in this report, CPRs and CPR systems offer many advantages (compared with current paper records) for overcoming some of these inefficiencies and improving health care quality. Hence, patients may have some basis for supporting the implementation of CPR systems.

Any influence of individual patients on CPR efforts is likely to be indirect at best. Patients might, for example, select providers on the basis of the provider's use of a CPR system. Greater influence can be exerted by the various voluntary membership organizations that represent the concerns of particular patient groups (e.g., the American Diabetes Association) or those of specific population groups (e.g., the American Association of Retired Persons). These organizations have the capacity to acquire a broad

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

understanding of the strengths and limitations of CPRs and CPR systems and to offer substantial support or opposition to CPR activities.

Provider Institutions

Health care provider institutions are likely to be interested in CPR systems in response to concerns about quality and costs and to internal and external demands for information. By purchasing a CPR system, provider institutions can influence CPR development and implementation in three ways. First, such action signals the market that demand for CPR systems exists. Second, it directly affects the staff who must use the system. Third, it can help to create an understanding on the part of both providers and patients that such systems are the emerging standard of practice.

Third-party Payers

Third-party payers include both insurers and employers. For insurers, CPR systems offer an opportunity to streamline operations. To realize the gains in efficiency and productivity offered by CPR systems, however, insurers may have to incur short-term costs to make their systems compatible with CPR formats. Long-term improvements in efficiency may also be realized; for instance, redundant data entry can be eliminated through electronic claims submission and payment.

Insurers have a major stake in improving the knowledge base for quality and cost management (e.g., clinical practice guidelines and utilization management), as well as for coverage and reimbursement decisions (e.g., technology assessment and outcomes research). As change agents, insurers could offer incentives—for example, faster payment of claims when they are submitted in electronic form. Alternatively, because third-party payers should value improved data, they could increase reimbursement rates to reflect the costs of implementing and operating CPR systems.

Employers are likely to be interested in CPRs as a means of improving the quality and reducing the costs of care received by their employees and related beneficiaries. Groups such as the U.S. Chamber of Commerce, the Washington Business Group on Health, and regional health care business coalitions have devoted considerable resources to finding ways to manage the utilization and cost of health care services, which are ultimately reflected in the health care insurance premiums employers pay. The potential for CPRs to improve information management at the micro (patient) and macro (population) levels is likely to be of interest to employers. Health care business coalitions, chambers of commerce, and major employers could all contribute to CPR development and implementation efforts by financially supporting research and pilot demonstrations and by developing relationships

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

with insurers and health care provider institutions that use or support CPR systems.

Federal Government

EXECUTIVE AGENCIES Federal agencies have varying degrees of interest in and authority to influence CPR development and implementation. Certain agencies can provide substantial funding for research and development; others may be able to finance the acquisition of CPR technology. Federal agencies can support standards development through funding or regulatory mandate. For instance, they can direct major federal providers of health care to use CPR equipment that meets certain standards, or they can require the use of CPR technology for hospital accreditation or Medicare participation. The remainder of this section outlines the change agent and stakeholder roles of selected federal departments and agencies.

Within the Department of Health and Human Services (DHHS), the Public Health Service agencies10 would benefit greatly from efficient access to complete, accurate patient care data; therefore, their interest in CPRs is likely to be high. For example, the Agency for Health Care Policy and Research (AHCPR) is charged to develop uniform definitions of data to be collected and used in describing a patient's clinical and functional status; it also supports the development of common reporting formats and linkages for such data and of standards to ensure data security, confidentiality, accuracy, and maintenance (U.S. Congress, 1989). These activities support or would be supported by CPR implementation.

The research institutes of the National Institutes of Health (NIH) are viewed as stakeholders who would benefit from improved patient data. Within NIH, the National Library of Medicine (NLM) is in a strong position to support CPR development directly through its medical informatics program and its work on the Uniform Medical Language System (UMLS). Further, MEDLINE, HEALTH, and other on-line databases of the NLM's MEDLARS (Medical Literature and Retrieval Systems) are valuable resources for health care professionals that could be made available through CPR workstations.

The Centers for Disease Control (CDC) and the FDA could each benefit from the implementation of CPR systems in two ways. First, CPR implementation would likely improve patient data for epidemiological research.

10  

These agencies include the Agency for Health Care Policy and Research, the Centers for Disease Control (including the National Center for Health Statistics), the Food and Drug Administration, the Health Resources and Services Administration, the Indian Health Service, and the National Institutes of Health (including the National Library of Medicine).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

Second, direct (i.e., electronic) reporting of events in which these agencies are interested could improve their public health and regulatory activities. Examples of crucial data include occurrences of tracked diseases and information about adverse events related to pharmaceuticals and medical devices.

The Health Resources and Services Administration (HRSA) administers federal support of maternal and child health (MCH) services amounting to more than $525 million a year.11 MCH programs offer demonstrably more difficult technical and practical barriers to successful implementation of CPRs and CPR systems than do, for instance, traditional hospital inpatient services or physician office-based practices. These obstacles must be recognized, understood, and planned for in the service of improved MCH care. The appendix to this chapter describes how CPRs and CPR systems could support HRSA in meeting its mandate.

The challenges to CPR implementation that are found in MCH programs are by no means unique. For CPRs to be productively and effectively developed and diffused throughout the U.S. health care system, implementers must confront and overcome precisely these kinds of barriers, especially as health care delivery moves more and more into outpatient and nontraditional settings and as it confronts complex "socioclinical" issues related to disadvantaged and underserved populations. Thus, the MCH arena should be seen as a particularly fruitful area in which to design, test, and implement practical computer-based systems for the 1990s.

The Health Care Financing Administration (HCFA) is responsible for administering the Medicare program and the federal portion of Medicaid. Because of the magnitude, scope, and complexity of these programs, HCFA has considerable motivation to improve the efficiency of claims processing, to assess the effectiveness and appropriateness of medical interventions, and to monitor the quality of care rendered. The agency is currently developing a computer-based patient record abstracting system, the Uniform Clinical

11  

HRSA uses two main types of funding. The majority of support is awarded to state health agencies through MCH block grants that are intended to enable states to ensure access to maternal and child health services for low-income individuals and individuals who live in areas of limited health resources. The purposes to which these funds can be put are quite broad—ranging from reducing infant mortality and the incidence of preventable diseases to improving the rates of use of diagnostic and therapeutic services.

Most of the remainder of MCH appropriations is disbursed through awards called special projects of regional and national significance (SPRANS). These programs can involve MCH research, training, and projects related to genetic disease testing and counseling and to diagnosis and treatment of hemophilia. More recently, amendments to Title V of the Social Security Act have directed that some funds be used specifically for newborn screening and for child health demonstration projects.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

Data Set (UCDS), to improve the efficiency of the Medicare peer review organizations (PROs; Krakauer, 1990). At present, the UCDS must be abstracted manually from hospital charts of Medicare patients; CPR systems would improve the efficiency of collecting these necessary data.

The HCFA Bureau of Program Operations engages in three activities that would benefit from widespread CPR technology. First, the bureau is trying to promote submission of claims by electronic media. Second, it is developing a so-called Common Working File, in which all claims for all kinds of services will be located and accessible upon inquiry. Third, it is seeking to develop a capability for real-time cooperation with PROs that will allow on-line authorization of services.

The Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508) provides for the development of prospective and retrospective drug utilization review (DUR) programs by states participating in Medicaid. 12 The act also includes provisions to conduct demonstration projects to evaluate the efficiency and cost-effectiveness of prospective DURs in patient counseling and reducing costs. Such demonstration projects, which would be overseen by HCFA, are likely to address issues of interest to CPR developers and could support CPR development efforts.

As noted in Chapter 3, the Departments of Defense (DoD) and Veterans Affairs (VA) have installed integrated medical information systems in numerous hospitals (GAO, 1988) and are actively engaged in developing and implementing components of a CPR. Widespread use of CPR systems can be expected to benefit both departments by expanding the availability of technology to meet patient care, research, and education needs. For example, with the CPR, the VA can improve its ability to coordinate health care services provided to veterans in both VA and non-VA settings. The

12  

Drug utilization review (DUR) is a formal program for comparing data on drug use against explicit, prospective standards and, as necessary, introducing remedial strategies to achieve some desired end. Three primary objectives of DUR are (1) improving quality of care, (2) conserving drug funding resources and controlling individual expenditures, and (3) maintaining program integrity (i.e., controlling fraud and benefit abuse). Retrospective DUR is a systematic process that involves selection, review, analysis, and interpretation of drug use data that are collected and analyzed after events occur. Retrospective DUR is used to identify drug utilization trends that warrant further education of practitioners and patients; it also highlights areas of system abuse that might call for more extensive peer-level review and provides mechanisms for evaluation and modification of program criteria and standards. Prospective DUR refers to systems that are designed to influence drug prescribing, dispensing, or use in a real-time environment. Implementation of such a system requires that a health care professional with patient care responsibilities have sufficiently detailed information regarding a patient's medical condition, drug use profile, and history to make an informed decision regarding new or renewed drug use (Norris, 1991).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

affiliation of VA medical systems with academic medical centers can be enhanced by providing consistency and flexibility for health care professionals at these dispersed sites, thus facilitating collaboration among affiliated institutions.

Although these departments have accomplished a great deal with respect to components of CPR systems, their primary mandate is not patient care. Thus, they cannot be expected to assume primary responsibility for leading CPR development throughout the health care field. Such large health care provider systems, however, can have a great deal of influence on what is developed and produced by vendors.

CONGRESS The potential for Congress to foster CPR development and implementation is great, but its present level of interest in such a course is unclear. Certainly, as evident from the IOM studies on quality assurance in Medicare (IOM, 1990a) and clinical practice guidelines (IOM, 1990b), Congress has expressed a desire to improve the quality of health care.13 Managing costs remains a critical issue, as is well illustrated by the work of the Physician Payment Review Commission (Lee et al., 1989) and the Prospective Payment Assessment Commission (ProPAC, 1990). Congress is also concerned about improving the quality and availability of health care data for research, a concern reflected in the establishment of AHCPR in late 1989.

Despite Congress's activities on behalf of improved health care, some obstacles to strong congressional support of CPR development may arise. For example, having allocated new monies to some of the efforts noted above, particularly certain parts of the AHCPR mandate, Congress may not see a need for additional specific support to improve patient records. That is, it may believe these problems are being addressed through existing mechanisms. Further, Congress may be especially concerned about the issue of privacy.

In the committee's judgment, better patient records are essential to achieving Congress's health care objectives. Consequently, the central role of the CPR in improving patient records and enhancing quality of care, in managing costs, in facilitating Medicare claims processing, and in improving available data for clinical and health services research must be made clear. Further, CPR advocates must seek to convince key members of Congress that through technological capabilities and legal remedies, CPR systems will bring about a net gain in protecting privacy compared with current record keeping systems.

13  

More recent evidence of Congress's interest in the quality of health care appears in the form of H.R. 1565, which was introduced in the House of Representatives on March 21, 1991. This bill is intended to increase access to health care and to affordable health insurance, as well as to improve health care quality and contain costs.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×
States

State governments face issues similar to those of the federal government in that they devote significant percentages of their budgets to health care and are concerned about health care quality, cost, and access for their citizens. States have also been fertile grounds for progressive policymaking and legislation. They have played important roles in developing regional databases to monitor quality, manage costs, and assess clinical effectiveness.14 State governments, cabinet-level health officers, and groups such as the National Conference of State Legislators, Council of State Governments, Association of State and Territorial Health Officials, and National Association of Health Data Organizations could provide a regional perspective in national CPR efforts. In addition, states would be likely candidates for pilot regional studies or experimental prototypes.

Universities and Professional Schools

CPR systems offer several advantages to universities. For example, universities whose professional schools (i.e., schools of medicine, nursing, and dentistry) are involved in clinical research can benefit from the improved data likely to be available for analysis. Furthermore, CPR systems may give the schools a means of disseminating their results for application in clinical practice. (These benefits are likely to accrue to independent research centers as well.)

The interest of health professions schools in CPRs may be mixed, however. On the one hand, faculty members' concerns about threats to their expertise and professional roles might prompt negative reactions to the CPR. On the other hand, individuals in academic or research settings might be

14  

The following descriptions are examples of the types of state activities already in progress (National Association of Health Data Organizations, 1988).

In 1977 New York established the Statewide Planning and Research Cooperative System (SPARCS), a public-private effort that provides a unified data system to gather information throughout the state regarding all hospital stays. SPARCS is a major management tool for assisting hospitals, agencies, and other organizations with decision making regarding the financing, planning, and monitoring of inpatient hospital services.

In 1985 the General Assembly of Colorado established the Colorado Health Data Commission to collect, analyze, and disseminate data as a way to encourage competition and informed decision making.

In 1986 the Pennsylvania Health Care Cost Containment Council was established through an act that mandates health care utilization and cost data collection and dissemination. Its central purpose is to increase purchaser and consumer knowledge of health care costs and quality.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

more innovative and more receptive to change than health care professionals in other types of settings.

Through the training of health care professionals (including continuing education), professional schools can both shape attitudes toward and provide the skills for using CPRs. Moreover, to the extent that professional schools influence the agenda of researchers (by providing space and support), they can foster the development of CPR systems. Some schools also now serve as centers of medical informatics training and of continuing research in medical informatics.

The NLM supports 11 institutions in efforts to develop prototypes of an Integrated Academic Information Management System (IAIMS). The objective of these projects is to ''develop the institutional information infrastructure that permits individuals to access information they need for their clinical or research work from any computer terminal wherever and whenever it is needed" (NAS, 1989). These projects may become models for linking the many departments of academic health and medical centers, including other departments in parent universities (e.g., economics, law, sociology) that have a role to play in clinical and health services research. IAIMS sites may also provide an infrastructure on which to base selected pilot CPR demonstration projects.

Standard-setting Organizations

Two kinds of standard-setting organizations are potential CPR change agents. The first is those groups that are developing standards for health care information systems, primarily in the areas of communication protocols and the characteristics of information collection and use. Among these organizations are the Institute of Electrical and Electronics Engineers (IEEE), the American Society for Testing Materials (ASTM), and the International Standards Organization (ISO). The second kind of standard-setting group comprises various health care accreditation organizations, such as the Joint Commission on Accreditation of Healthcare Organizations, the National Committee on Quality Assurance, and the National League of Nursing. Their role may be to foster CPR development, acquisition, and use by setting standards for accreditation that are most effectively met through CPR systems.

Vendors

CPR system vendors are likely to support development if the projected demand for CPR technology seems sufficient to recoup investment and marketing costs. As discussed earlier, however, vendors are uncertain about the willingness of health care providers to purchase CPR systems. Users or

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

other change agents (such as Congress) may need to provide incentives for a greater or more certain CPR market before vendors can be expected to invest major sums for research, development, or marketing.

Activities and Resources Critical to CPR Development

In light of the various barriers to CPR development, the interest and resources of change agents, and the concerns of stakeholders, the committee identified eight critical activities that will help to advance CPR development: (1) identification and understanding of CPR design requirements; (2) development of standards; (3) CPR and CPR systems research and development; (4) demonstrations of effectiveness, costs, and benefits of CPR systems; (5) reduction of legal constraints for CPR uses as well as enhancement of legal protection for patients; (6) coordination of resources and support for CPR development and diffusion; (7) coordination of information and resources for secondary patient record databases; and (8) education and training of developers and users.

Dedicated resources and improved organization must be provided to accomplish these activities. Resources can take the form of funding, expertise, and equipment. Without adequate funding, however, the other kinds of resources are unlikely to be available. Funding is required to support standard setting, research, demonstrations, review of legal issues, information coordination, education, and a user-developer forum.

Potential sources of funding include federal and state governments, vendors of CPR systems, and private foundations. The committee believes that funding for CPR development should be a governmental priority because the CPR is essential to achieving a variety of ends desired by government (e.g., improved patient care and research). The budget deficits faced by federal and state governments, however, may make the infusion of significant new funds difficult. CPR vendors may be willing to contribute some funds but probably not enough to support all needed activities. Vendors may be more likely to contribute when uncertainty regarding the market for CPR systems has been reduced. Foundations and other groups in the private sector that support health-related research and educational activities may also be an important, indeed, necessary source of funding; again, however, the sums available from this source will not be sufficient to support the entire task envisioned by the committee. Purchasers of systems are unlikely to provide funding for development efforts. They may be willing, however, to contribute in-kind support, for instance, through their participation in demonstration projects.

Substantial levels of resources are already devoted to CPR system development, and this suggests that a major effort should be made to avoid duplication of effort and to build on expertise that has already been developed.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

The need is great to coordinate CPR-related activities, enhance collaboration, and eliminate potential inefficiencies in the development process. Experience gained from working with currently available data is likely to benefit CPR development. The needs of secondary patient record users may be better met in the interim (i.e., until CPR systems are widely used) through enhancements to existing databases—similar to the approach AHCPR is currently pursuing for research.

Organizational Structure

Health care providers spend large amounts of money on computer and software systems that may not meet their needs today and that will not meet their needs tomorrow.15 Complete, accurate, accessible patient care data are needed now for clinical care and research. The current combination of private sector, public, and voluntary efforts cannot adequately address the many issues that affect and are related to CPR development and diffusion. Progress is essential on several fronts: coordinating existing and new activities; maximizing public funding; strengthening voluntary efforts (e.g., standard setting); developing a national consensus; and establishing a framework for local efforts.

No one organization currently has the mandate and resources necessary to provide leadership for the CPR effort. Further, the committee concluded that the complexity and importance of the task required an organization dedicated to the CPR mission—such an arrangement would be more likely to foster progress than ad hoc efforts by a number of organizations. Therefore, an initiative should be mounted to create the necessary organizational apparatus, identify and accumulate resources, and pursue the activities noted earlier. This initiative could involve either a new organization created for this purpose or an existing organization that could be given an expanded mission. The organization's fundamental goal would be to facilitate endeavors that improve the flow of information and reduce uncertainty so that a true market for CPRs and CPR systems could function.

Some of these activities are under way, but they are not coordinated with other CPR or CPR-related ventures. Moreover, existing efforts lack authority and national attention. There is also no established mechanism for setting priorities for CPR development or for representing CPR interests on an ongoing basis. The committee believes that the establishment of a formal leadership role is essential for CPR implementation success.

The committee further believes that this leadership role should be established in an organization with the following mission:

15  

Nonfederal hospitals in the United States spend more than $5 billion per year on computing-related products and services (Booz-Allen and Hamilton, 1990).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×
  • Support the effective, efficient use of computer-based patient information in patient care, health care policymaking, clinical research, health care financing, and continuous quality improvement.
  • Educate change agents and stakeholders (including the general public and health care professionals) about the value of computer-based patient data in improving patient care.
  • Foster the CPR as the primary vehicle for collecting patient data.
  • Promote the development and use of standards for CPR security and data content, structures, and vocabulary.

Specific steps the organization should take to achieve this mission include the following:

  • Establish a forum for CPR users and developers to address such issues as definition of CPR functions and content.
  • Facilitate data and security standards setting and endorse such standards.
  • Promote CPR data transmission through national high-speed networks by representing the biomedical community in planning for such networks.
  • Address legal issues related to CPRs and CPR systems.
  • Develop mechanisms for sharing the costs of acquiring and operating CPR systems among all users of CPR data.
  • Define priorities and criteria for CPR demonstration projects that could be used by federal agencies, private foundations, and health care provider institutions.
  • Conduct workshops and conferences to educate health care professionals and policymakers.
  • Explore the need for a clearinghouse or data center for secondary CPR information.

Given the mission and objectives outlined above, the committee concluded that any organization leading the effort to advance the implementation of CPRs should have several key attributes. First, it should be national in scope. Second, it should have authority to make and implement decisions. Third, it should represent all CPR users, as well as CPR developers. Fourth, it must have sufficient visibility and influence to be able to achieve measurable progress within a relatively short time. Three to five years was seen as a reasonable time frame for initial headway to be made.

The committee had particular concerns about the feasibility of establishing and operating such an organization. To clarify the issues further, it examined several organizational models in terms of the need for and ability to secure funding, receive a mandate, and gain acceptance. The three main options explored by the committee were a purely governmental (federal) effort, a purely private sector entity, and some form of a public-private

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

commission, consortium, council, or institute. The advantages and disadvantages of these options are discussed below.16

Federal Agency

There are several advantages to a federally based CPR development effort. In general, a federal initiative associated with an existing agency has implied authority and power, as well as lower start-up and operating costs than would be incurred for a newly created, freestanding organization. Moreover, congressional support is likely to be stronger if the CPR effort is closely linked to federal efforts that are already under way. In addition, staff would not need to spend time raising funds as would be necessary for a private sector effort.

A federal agency would have less independence than a private sector organization, however, and would face possible limitations from bureaucratic policies and procedures. Thus, greater potential for innovation might exist in the private sector. Another disadvantage to locating leadership for CPR development within the federal government is the potential for health care providers to see such efforts as too closely aligned with government and therefore open to excessive regulation and intrusiveness. Finally, such an approach must rely on receiving a mandate and funding, which could make start-up time for federal efforts longer than for a private organization.

Within DHHS, several agencies might be considered. First, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) might be able to bridge the gaps among various agencies and programs in DHHS. It would be unlikely, however, to gather the resources and expertise required to mount an effort of the magnitude envisioned by this report.

AHCPR has functions quite consistent with the objectives of the leadership entity proposed by the committee, although these functions are not its primary responsibilities. Currently, AHCPR does not have the resources to undertake a CPR implementation project, but if such funding were forthcoming it could, over time, assume a more significant role. One drawback, however, is that such an effort might be seen as possibly undermining the agency's main mission—that is, support of health services, outcomes, and effectiveness research and the development of clinical practice guidelines.

HCFA has a substantial interest in the CPR for both operational and quality improvement reasons. Although HCFA would be a key beneficiary of widespread CPR implementation and hence likely to want to provide

16  

To address this issue fully, the committee organized a one-day workshop in September 1990 to evaluate the feasibility and desirability of alternative organizational models for a CPR organization; AHCPR provided separate funding for the meeting. Workshop participants included representatives of health care professionals, provider institutions, federal agencies, insurers, employers, and private foundations.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

critical resources, it may not be the ideal agency to champion patient record development. If HCFA were to lead the CPR effort, health care providers might not be able to separate it from HCFA's other activities, particularly regulation of the Medicare program, cost containment, and related efforts. Providers might resist the CPR development initiative because of a perception that it was intended as a cost-containment mechanism rather than as a way to improve health care delivery.

The Departments of Defense (DoD) and Veterans Affairs (VA) are both making significant investments in comprehensive medical information systems.17 As a result, they have a great deal of expertise in designing and implementing such systems. These departments do not seem likely candidates for leading a CPR initiative, however, because of their restricted populations and other non-health care responsibilities. In short, no existing federal organization simultaneously has the mandate, mission, credibility, and resources to take on this responsibility.

Private Sector Sponsorship

The committee also considered a private sector, not-for-profit membership organization, similar to the Joint Commission on the Accreditation of Healthcare Organizations, to lead the CPR development effort. A decided advantage to a purely private approach is that the conversion to computer-based records would become something championed by, rather than imposed on, these organizations and their constituents. The active involvement of such organizations might prompt them to provide core funding, and the efforts to secure funding from others might then be more effective. In addition, staff recruitment for a private organization would be facilitated by the broad-based support the organization would receive from national health care groups.

This strategy has its limitations, however. Most important is that such an organization would lack the power and authority implicit in a governmental entity. Further, federal funding could be difficult to obtain unless key agencies played a major role in the organization's activities.

Public-Private Commission or Consortium

In theory, a public-private organization would offer the advantage of involving and being able to draw on funding and personnel resources from

17  

DoD is acquiring the Composite Health Care System for installation in its 167 hospitals and nearly 600 clinics. The costs for full deployment of this system are expected to be $1.6 billion. The VA is installing the Decentralized Hospital Computer System to support its 172 hospitals and 358 outpatient facilities. The VA estimates that this system as currently defined will cost $925 million (GAO, 1988, 1990).

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×

both sectors. Furthermore, because the problems with patient records affect both public and private organizations, acceptance of a solution would be more likely if both sectors were involved in the decision making process.

The drawbacks of a public-private entity should not be underestimated, however. Managing the diverse interests that would be represented in such an organization presents a major challenge. Certain federal agencies already have charters that would overlap the charge to such an organization. In addition, a purely private sector organization might offer more entrepreneurial agility than a hybrid group. Perhaps the biggest drawback of a public-private organization is the inherent instability of such an approach. Lacking a federal mandate and given the less-than-immediate contribution to the profitability of private sector participants concerned with CPR development, a public-private organization may not command sufficient resources and attention to address effectively the barriers to CPRs and CPR systems.

Preferred Approach

The committee recognizes that the federal sector has considerable resources (including authority and knowledge) to influence CPR development. For example, HCFA can establish reimbursement mechanisms that reward providers who submit insurance claims generated by CPR systems. AHCPR is expressly mandated to improve patient data for research. The VA and DoD have gained considerable experience in CPR development and implementation. NLM has made significant contributions to the management of medical knowledge for practitioners.

Nevertheless, several factors militate against a purely federal approach. First, the resources, potential change agents, and stakeholders that must be coordinated or engaged in CPR development are present in both the public and private sectors. Thus, a structure is needed that can draw from both sectors. Second, the committee believes that routine use of the CPR can be achieved most efficiently through a collaborative process that develops consensus on key issues (e.g., data and security standards, the minimum content of CPR systems) yet allows flexibility at the local level to foster innovation in the development and use of CPRs.

Third, the committee believes that patient care should be the primary focus of CPR development and implementation. Practitioner use of CPR systems requires that the systems meet practitioner needs, and only if practitioners are willing to use CPR systems to capture data and to secure assistance in clinical decision making can the benefits of CPRs for moderating costs and conducting research be realized. It is essential that practitioners view the CPR as a valuable resource for improving patient care. Thus, CPR efforts must involve health care providers as well as federal agencies.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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CPR design should not be driven solely by governmental objectives—for example, those embodied in the cost-containment and health outcomes research missions of HCFA and AHCPR, respectively. Although those agencies are likely to have significant interest in CPR development, their primary mission is not patient care.

The committee concluded that a public-private approach would be optimal in the long run and, as elaborated in Chapter 5, proposes the establishment of a Computer-based Patient Record Institute (CPRI). It was also of the view that the potential base of funding in the private sector is not sufficiently solid to provide adequate support for a new organization at this time. This judgment was founded on its review of the history of CPR development and on a poll of the participants at the workshop noted earlier. As a result, the committee also concluded that a federally initiated and funded approach would be most appropriate for necessary interim activities.

Immediate action is needed to advance CPR efforts and to lay the groundwork for an organization such as the CPRI that would ultimately coordinate the necessary infrastructure for a national CPR system. Many of the barriers to CPR implementation relate to lack of information; part of the interim effort thus should focus on education and evaluation. Standards development and representation of the interests of health care in the national high-speed computer network discussed earlier should also be given high-priority attention. The overall goal of such efforts would be, within five years, to turn over operational issues to a public-private organization that is supported mainly by its members.

The committee noted that if the private sector failed to support CPR efforts adequately, the federal government might still be sufficiently motivated to advance the CPR unilaterally. Long-term dominance by the federal government in this area could result in an approach that was more regulatory and bureaucratic than collaborative and innovative. To preclude such an eventuality, the committee placed special importance on joint public and private sector progress.

This approach is consistent with the recent General Accounting Office report on automated medical records (GAO, 1991), which made two recommendations to the secretary of Health and Human Services. First, as part of DHHS's mandate to conduct research on outcomes of health care services, the secretary should "direct the Public Health Service, through its Agency for Health Care Policy and Research, to support the exploration of ways in which automated medical records can be used to more effectively and efficiently provide data for outcomes research" (GAO, 1991:26). Second, as part of the effort to support outcomes research, the secretary should "develop a plan and budget for consideration by the Congress, to bring about the greater use of automated medical records" (GAO, 1991:26). Specific elements of such a plan could include "a national forum that

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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sets goals for automating medical information, addresses individual and organizational concerns with automated records, and identifies incentives to induce health care organizations to increase their use of automation" (GAO, 1991:26).

Specific Steps for Change Agents

The challenges of developing affordable CPR systems that are acceptable to users and of achieving widespread use of such systems within a decade should not be underestimated or understated. Much of the progress toward these goals is likely to occur incrementally over time and across the country. The CPRI can play an important role in tracking progress and directing future efforts, but significant contributions to CPR development and implementation can and must be made by individuals and groups other than the CPRI. A great deal of work can be accomplished at the regional, local, and institutional levels in preparation for CPR implementation.

  • As discussed earlier in this chapter, health care professionals could support development and implementation by helping to plan and conduct research or demonstrations of CPR systems. Involvement of all kinds of CPR users is needed—especially practitioners as the primary source of data—to design systems that will meet their requirements.
  • Professional societies could implement formal education and awareness programs as part of their membership mailings and annual meetings. They could also support conferences at which CPR users could share experiences, report on useful experiments in various settings, and meet with other professional disciplines to discuss data and function needs.
  • Purchasers of CPR systems could actively seek systems that are able to meet basic data-exchange and security standards and offer sufficient capacity to evolve over time.
  • Insurers could offer incentives (e.g., faster payment of claims) for data that are provided in electronic form.
  • Health care business coalitions, chambers of commerce, and major employers could all support CPR development and implementation efforts by supporting research and pilot demonstrations as well as by developing relationships with insurers and health care provider institutions that use or support CPR systems.
  • Federal agencies could provide substantial funding for research and development and support standards development through funding or regulatory mandate.
  • States could serve as candidates for pilot regional studies or experimental prototypes.
  • Health care accreditation organizations could foster CPR development,
Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
×
  • acquisition, and use by setting standards for accreditation that are most effectively met through CPR systems.
  • In their training of health care professionals (including continuing education), professional schools could both shape attitudes toward and provide the skills for using CPRs. They could also foster the development of CPR systems to the extent that the agenda of researchers is influenced by the schools' provision of space and support.
  • Researchers could study the costs and benefits of CPR systems, at both micro and macro levels, including the impact of CPR systems on the quality and costs of care.
  • State agencies, hospital associations, and local professional groups could establish working groups to develop a common understanding and vision of how CPRs could support their health care environment and to identify the elements of local and regional infrastructure needed to support future CPRs. Working groups could study the relationships among referring physicians and among other providers to understand their entire system of health care. They could also define needed data elements, educate local health care professionals on health care information management issues, and monitor progress in the development of standards for security and data exchange.

Summary

In addition to technological advances, successful implementation of CPR systems requires elimination of the barriers to development and diffusion. It also requires that the concerns of stakeholders be addressed and that potential change agents be engaged.

Many impediments to the CPR arise from a lack of awareness and understanding of CPRs and their capabilities. System purchasers and users lack adequate information about the benefits and costs of CPRs. In particular, developers and vendors require more specific information about what users want from systems and what price providers would be willing to pay for systems that meet their needs. Activities aimed at improving (e.g., demonstration projects) and disseminating (e.g., education programs) available information about CPR systems constitute an important step for CPR implementation.

Other impediments arise from the lack of an infrastructure to support CPR development and diffusion. Such an infrastructure comprises standards for communication of data (i.e., vocabulary control and data format standards); laws and regulations that protect patient privacy but do not inhibit transfer of information to legitimate users of data outside the clinical setting; experts trained in the development and use of CPR systems; institutional, local, regional, and national networks for transmitting CPR data; reimbursement mechanisms that pay for the costs of producing improved

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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patient care information; and a management structure (i.e., an organization) for setting priorities, garnering and allocating resources, and coordinating activities. Removal of these impediments is essential to the timely development and implementation of CPR systems.

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Appendix: Maternal and Child Health Care and Computer-Based Patient Records

As discussed in Chapter 3, much of the progress to date in implementing CPRs and CPR systems has occurred in hospitals and large multispecialty practices, particularly in health maintenance organizations. To be successful, however, CPRs and the larger computer-based systems in which they function must be useful and practical for many other types of providers, including, for instance, community-based clinics and other outpatient facilities serving either primary care or special health care needs. In this category might fall services to disadvantaged populations such as those eligible for maternal and child health care through Title V of the Social Security Act.

The area of maternal and child health (MCH), both generally and as administered by the Health Resources and Services Administration (HRSA) in support of the Title V mandate, poses particularly interesting challenges and opportunities for CPRs and CPR systems. Five topics are briefly discussed here as examples.

First, the challenges involve, among other matters, the capability to track populations that typically do not have regular providers of care; that move in and out of eligibility for the services; that move in and out of geographic areas (e.g., states, underserved regions) where the services are provided; and that are in many ways socially, economically, and demographically disadvantaged. In such circumstances, ease of data entry, storage, and transmission of clinical and sociodemographic information takes on special importance. CPRs can maximize these attributes, especially in comparison to traditional paper records that are often institution-specific, fragmented, illegible, and lacking in information related to social support, health education, and similar nonclinical issues. Another important factor in reaching these populations is coordination of care across many different sites. Computer-based systems will facilitate timely, accurate movement of necessary information and collaboration among those delivering both clinical and social services.

Second, MCH programs are expected to reach out to obstetricians, gynecologists, and pediatricians throughout the states, to develop integrated

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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MCH service delivery programs, to improve home visit programs (including those concerned with case management), to collaborate with inpatient institutions delivering care to children with special health care needs, and to improve services to rural populations. CPR systems should make it easier to achieve these objectives by making clinical and sociodemographic data more readily available even in relatively nontraditional settings. Certainly the expectation of CPR developers and innovators is that their technologies, when broadly implemented, will offer capabilities far beyond what can be achieved with today's paper medical charts, particularly in terms of longitudinal records in which, for instance, information about immunizations and screening services must be maintained over a considerable period of time.

A third major challenge facing HRSA and its MCH bureau is the required implementation of relatively recent mandates of Title V that call for development and maintenance of a data and information system. Part of this system presumably would involve the acquisition of pertinent epidemiological data that can be used by the bureau and others to improve and promote health and prevent disease among mothers, infants, children, and others eligible for MCH block grant services. To the extent that CPRs and CPR systems allow institutional providers and practitioners (e.g., physicians, visiting nurses, clinic staff) to enter data once (and only once) for both clinical and administrative purposes, they will considerably simplify the reporting requirements of these programs. Moreover, the expectation is that CPR systems ultimately will communicate with each other with the aid of a composite clinical data dictionary (CCDD); this means that states, and the providers and clinicians who operate in them, will not need to conform rigidly to a single federal data system in meeting HRSA's reporting requirements (because the federal system itself would be a party to the CCDD).

A fourth way in which the movement toward CPRs and CPR systems may be important for MCH activities concerns the support of research. As a general proposition, researchers are more accustomed to the use of computers for data gathering and analysis than are clinicians, so movement toward the implementation of such systems presumably would be regarded as welcome progress by those involved in MCH research. Indeed, one specific aim of research grants in this area is to use automated systems to facilitate the management and delivery of health care for target populations.

One special aspect of the research effort involves infant mortality and Medicaid (Title XIX) services. The secretary of Health and Human Services is expected to develop a national data system for linking vital statistics (birth and death) records with information on Medicaid insurance claims forms. This task clearly lies within the realm of CPR development.

In a related vein, special projects may be mounted to enhance family-centered and community-based health care, both within and across states.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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These projects could benefit greatly from a capacity to acquire large amounts of information, locate those data securely in a single site (for analysis and archival purposes), and make them available to properly authorized users for analysis (and perhaps for clinical purposes as well). The collection, storage, maintenance, and use of such information through computer-based systems, rather than through paper records (or paper records secondarily data-entered into computer files), can be expected over the long run to promote more comprehensive and more productive special projects on this and other complex topics (e.g., services to children with serious impairments and handicaps such as spina bifida, debilitating chronic illnesses, or cleft lip and palate).

The fifth point relates more specifically to the potential value of communication and collaboration across federal agencies. Several federal departments have already taken steps to design and implement one or more components of a CPR system. Notable among these are the Departments of Defense (DoD) and Veterans Affairs (VA). Both departments have health care delivery responsibilities for distinct, and sometimes quite dispersed, populations that have both traditional primary care needs (e.g., for screening and prevention) and health care problems at least equivalent in complexity and severity to those facing disadvantaged MCH populations. Both departments also have considerable health research programs. Lessons from their efforts to date may prove helpful in planning computer-based systems to serve MCH needs; conversely, issues that arise in planning for and delivering services to disadvantaged MCH populations might be posed to DoD and the VA as a means of bringing difficult technical questions to their attention.

In addition, the Health Care Financing Administration (HCFA) has mounted an interesting effort to develop a ''uniform clinical data set"; although it is oriented toward hospital care (and care for the elderly), its developmental history to date offers useful and perhaps cautionary lessons for others attempting to develop clinical data sets and data dictionaries. Certainly it would be important for HCFA developers to understand the special needs and perspectives of a computer-based data set oriented more toward Medicaid than toward Medicare.

Finally, the Agency for Health Care Policy and Research (AHCPR) has a specific congressional mandate to work toward the development of computer databases that will serve broad clinical evaluation purposes. Part of AHCPR's interest has been specifically in computer-based record systems, including the potential for a public, or public-private, entity to undertake many technical, legal, and other tasks related to the establishment of CPRs and CPR systems nationally over the next decade. Because the MCH component of HRSA will have wide concerns about quality of care, outcomes of care, and similar issues, it would seem prudent for HRSA to work together from the outset with a sister Public Health Service agency on many of these subjects.

Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Suggested Citation:"4 The Road to CPR Implementation." Institute of Medicine. 1997. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: The National Academies Press. doi: 10.17226/5306.
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Next: 5 Improving Patient Records: Conclusions and Recommendations »
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Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions:

  • Who uses patient records?
  • What technology is available and what further research is necessary to meet users' needs?
  • What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
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