Computerized medical records: the need for a standard.

Major concepts introduced in this paper are as follows. 1) Organization, with its attendant qualities of accuracy, consistency, legibility, completeness, and simplicity, is the heart of the medical record. Technology should not be allowed to obscure this goal. 2) The main function of the computerized medical record is data storage with the qualities of organization noted above. This function must be clearly separated from condensation, analysis, or other secondary manipulation of data. 3) Many aspects of data manipulation call for the judgment of a physician. This judgement may be aided by computer software, but not replaced by it. 4) Present technological barriers, most notably speed, permanent large storage, and voice input should not influence the design of the effective computerized record. Future technology will be able to service the carefully designed medical record. 5) Textual parts of the computerized medical record can follow a simple and machine independent outline format. All parts of the record should use a textual introduction emphasizing patient and record identification. 6) A patient profile is central to each patient file. Updating this profile as needed must be recognized as a primary function of the physician at every patient encounter. 7) Acceptance of a standard for the computerized medical record now, before technology has matured and software diversified, will avoid a pitfall commonly experienced in other fields and save substantial healthcare funds. This standard should be geared to the needs of physicians and patients, not to the constraints of technology. The future of medical computing is bright. Obstacles to the practical use of the computerized medical record exist, but we may expect these to vanish within a few years. The great challenge to physicians now is to take this opportunity to control a new technology, rather than to be driven by it. The soul of good medicine is not in the equipment available, but in the rational and carefully thoughtout use of those tools at hand. We must recognize now the need for a uniform style of computerized medical record before the technological establishment besieges us with a flood of specialized, non-interchangeable, and expensive machines. Indeed, a bit of careful thought now as the foundation is laid can prevent the tangled confusion so typical of new technology. We have a golden opportunity to avoid a new round of escalating medical costs.