The computerized clinical record: merely an academic discussion or an essential technology?.

Abstract

The publication of the results of a study on improving patient records, recently completed by the Institute of Medicine of the National Academy of Sciences, in the United States, where it was concluded that the Computer-Based Patient Record (CPR) was an essential technology for health care, witnesses the importance and expectations that patients, physicians and other health care professionals, hospital administrators and health systems managers, place on forms of management of clinical information that are more accurate, complete and efficient than what is possible with current methods. A large amount of work is in order, to develop standards for sharing clinical data between clinical information systems and for representing medical terminology and knowledge, to create legislation regarding data protection in CPR, and for the preparation of health care professionals for the information and technological demands of the future. Recent developments in database integration, and the experience of several CPR systems developed at academic institutions, have led to the progressive delineation of the architecture of modern CPR systems.