mini MHA
health informatics

What Are the Records and Database Issues?

What Might be Computerized?
Patient health information
Patient demographic information
Patient financial information
Research Information
Information about physicians, nurses, and other caregivers
Peer review information
Information about payers
Business records including financial records, personnel records, practice patterns, quality assurance statistics, strategic plans, and similar information.
Computer software

Computerized Patient Records ......
Medical Record is " medical record can be defined as a repository for information and data collected from a patient's encounter with the health-care system."*

Medical records exist to: (a) facilitate patient care; (b) serve as financial and legal records; and (c)support clinical research.

Generally, records are (a) handwritten; (b) stored in folders on shelves; (c)inaccessible for analysis; (d) not useful for decision-making.

Problems associated with current "generation" of records:
1.content - missing, illegible, redundant, and inaccurate information
2.format - unstructured, disorganized, and improperly sorted information
3.access, availability, and retrieval - incorrect location, inefficient storage, and difficult information "mining"
4.linkages and integration - inpatient/outpatient discontinuity, non-transferability, and lack of inter-institution cooperation

A Computerized Medical Record is "computerized medical record is one that stores said information digitally."*

Computerization is important:
To provide a continuum of patient care information
Need for enhanced documentation
Quality Management movement
Demands of health care reform for better clinical information
Need for data repositories
The relative efficiency of computers in searching and retrieval operations

Ideally computerization has as its first priority support of the clinical decision process in a manner that improves patient care quality.

Attributes of good computerization*:
Provides problem list
Measures health status
Documents clinical reasoning
Provides linkages
Protects from unauthorized access
Supports continuous access
Supports simultaneous multi-user views
Supports other clinical resources
Features clinical problem solving
Supports direct data entry by physicians
Supports management of patient care
Provides flexibility and expansibility

For more information on Medical or Patient Records, see
Overview of Computerized Patient/Medical Records

Once computerized, all the problems begin ....

There are too much data and not enough information.
Clinician's Information Needs
From Movable Type to Data Deluge
Information Overload

The Solution to Some Problems is the Data Warehouse
What is a Data Warehouse
Data Warehouses

Data Warehouses Allow Data Mining
Data Mining
Data Minefields

Computerized records are easier to find, read and combine, so security becomes an even bigger issue.
Confidentiality of Computerized Records
Confidentiality Agreements
Information Security

Examples of Computerized Systems
Informatics System from MIT
Informatics Systems from Columbia University
Online Medical Records Documents from University of Florida


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