1. Introduction

Over a patient’s lifetime, a patient may be seen in many different healthcare organizations by many different physicians and nurse practitioners, and thus have many separate paper medical records. There is an urgent need to combine these medical records to produce a single universal patient record.

This book and research paper [1] shows in detail how the patient medical record could be automated in healthcare organizations to produce such a universal patient record. As an example healthcare organization where automation would first occur, it uses a Health Maintenance Organization (an HMO).

Many organizations have tried, with limited success, to automate the patient medical record. People designing such systems either do not have an understanding of large healthcare organizations where such a system would be most useful, or they do not have the multi-dimensional background needed to create such a system. They attempt to build parts of the system without considering the whole. They build or chose a system based upon its user interface rather than looking at the larger picture of infrastructure, integration and scalability. They have the misplaced idea that the best system is one tailored to their own healthcare organization and no others. In their system they fail to build bridges to the past or fail to build bridges to the future. Or they assume that the system is for physicians rather than for patients. This book shows how to automate the patient medical record and addresses these inadequacies of past systems.

Because an automated patient medical record on a large-scale does not yet exist and there may be many forms that it might take, simply describing such a patient medical record in detail would be presumptuous at this time. Instead, this book presents a project plan for development of an automated patient medical record in an HMO and presents possible and alternative results of this development effort. This book shows how a universal patient record is likely to evolve and how an automated patient medical record should be designed from the very beginning to be compatible with such a universal patient record.

Going through the thought processes of a project to develop an automated patient medical record, one has to view the automated patient medical record from a “project perspective”, i.e., from many different points of view that must be consistent with each other, as this is what must be done on any well-managed project. Some of these many mutually consistent points of view are the following: business, patient care and best medical practices, public health, project management and costs, universal patient record, healthcare and computer standards, current and future technology, law and legislation, caregiver workflow, user interfaces, computer software and hardware systems, and research.

In this project, the organization for which the automated patient medical record system will be initially implemented will be a particular type of healthcare organization, a Health Maintenance Organization (HMO). An HMO is a corporate entity that provides comprehensive health care for each member of the HMO for a fixed periodic payment paid in advance by the member or his employer. Such a payment system is referred to as “capitation”. The HMO has its own hospitals and medical offices spread throughout the United States. This is a fictional HMO, but is representative of a very large HMO in the United States.

The approach this book takes is first to describe how to do any large-scale complex project in a healthcare organization and then to apply these ideas to the project to develop an automated patient medical record in an HMO. The title of each chapter relates to the automated patient medical record project, with the first section of most chapters labeled “project context: …”, relating to the larger idea of doing any large-scale complex project in a healthcare organization. For example, chapter 4, titled “patient care in the HMO using paper medical records”, has a first section titled “project context: describing the current environment and systems”; thus each chapter has essentially two titles, one related to the automated patient medical record project and one related to doing a large-scale project in general.

The reasons for following this dual approach are three-fold:

1. The description of how to do a large-scale complex project in a healthcare organization forms a basis for discussion of the project to automate the patient medical record.

2. Although the same project development techniques might be used, the group that actually develops such an automated patient medical record may come up with different project results than presented here, as these results depend upon the needs of the healthcare organization developing the system, technology, standards agreements, societal factors, design choices, and many other unpredictable factors.

3. These project development techniques presented here could also be used by other large-scale projects in a healthcare organization.

The intended readership of this book are healthcare professionals: physicians, nurses and other caregivers, and healthcare organization managers and public health analysts. The intended readership also includes business and computer professionals: business analysts, system analysts, database analysts, and project managers. More specifically the intended readership of this book is anyone who is interested in the field of medical informatics, the use of computers in medical care.

Of particular interest to healthcare professionals are chapter 4 (patient care in the HMO using paper medical records), chapter 5 (reasons to develop an automated patient medical record), chapter 6 (steps toward a universal patient record), chapter 7 (business requirements for an automated patient medical record), chapter 8 (anticipated future use of the automated patient medical record), chapter 10 (obstacles to automation of the patient medical record), chapter 11 (reengineering the HMO for the automated patient medical record), chapter 12 (example user interfaces for various caregivers), chapter 15 (an example phase to develop a Clinical Data Repository (CDR)), chapter 17 (incorporating research and advances), chapter 18 (the automated patient medical record and universal patient record in perspective), appendix (healthcare standards).

Of particular interest to healthcare organization managers and non-healthcare professionals, especially those in the computer field and project management, are the following chapters (with the alternative chapter titles): chapter 2 (how to do a large-scale complex project in a healthcare organization), chapter 3 (identifying a project), chapter 5 (determining project objectives from organizational objectives), chapter 7 (deriving business requirements), chapter 9 (the decision to continue, terminate or change the project after the initial business analysis) chapter 10 (obstacles to the success of a project), chapter 11 (business reengineering of an organization for a project), chapter 12 (user interfaces), chapter 13 (systems analysis and design), chapter 14 (project plan—breaking the project into subprojects, or “phases”), chapter 16 (monitoring, control and maintenance of a project), and chapter 17 (incorporating research and advances in a project).

Together, these chapters form a comprehensive project plan for development of an automated patient medical record system that could evolve into a universal patient record. Possible results of each step of the project are also presented. (Note that these possible results are less detailed than the actual results that would occur in such a project.)

Individual basic concepts applying to computers, medicine, or the automated patient medical record are in bold. Definitions of these concepts appear in the Glossary of this book.

Various terms have been used for what this book calls the automated patient medical record, including electronic medical record (EMR), electronic health record (EHR) and computer-based patient record (CPR), with definitions that vary from organization to organization (see references [1, 2]). This book views the term "automated patient medical record" as an evolving entity, so the term is given a broad definition: "Patient medical records available over a network".

References

[1] Joseph Gibaldi, MLA Handbook for Writers of Research Papers, Fifth Edition, The Modern Language Association of America, New York, 1977, 1984, 1988, 1999.

[2] See http://www.ama-assn.org/ama/pub/category/2900.html for some definitions of the electronic medical record and computer-based patient record.

[3] See http://www.medrecinst.com/resources/pat_right/whatis_ehr.shtml for some definitions of electronic health record, electronic medical record, and computer-based patient record.

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