The patient record is the principal repository for information concerning a patient’s health care

The patient record is the principal repository for information concerning a patient’s health care. It affects, in some way, virtually everyone associated with providing, receiving, or reimbursing health care services. Despite the many technological advances in health care over the past few decades, the typical patient record of today is remarkably similar to the patient record of 50 years ago. This failure of patient records to evolve is now creating additional stress within the already burdened U.S. health care system as the information needs of practitioners,1 patients, administrators, third-party payers, researchers, and policymakers often go unmet. As described by Ellwood (1988:1550),

The intricate machinery of our health care system can no longer grasp the threads of experience… Too often, payers, physicians, and health care executives do not share common insights into the life of the patient… The health care system has become an organism guided by misguided choices; it is unstable, confused, and desperately in need of a central nervous system that can help it cope with the complexities of modern medicine.

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Patient record improvement could make major contributions to improving the health care system of this nation. A 1991 General Accounting Office (GAO) report on automated medical records identified three major ways in which improved patient records could benefit health care (GAO,