The Computer-Based Clinical RecordWhere Do We Stand?

The practice of medicine depends on how we record, process, retrieve, and communicate information. Physicians are often frustrated with the inadequacies and duplication of the existing paper-based medical record and with the time wasted in locating medical information. The recognition of the need for more comprehensive and available documentation of patient care is not new. In her 1863 book Notes on a Hospital, Florence Nightingale wrote, In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. If they could be obtained they would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good [1]. The need to improve the management of medical information is more critical now because of the explosion of medical knowledge and because of the need to provide comprehensive documentation of patient care for an ever-growing list of interested parties [2].

The article by van der Lei and colleagues in this issue of Annals [3], which describes the introduction of computer-based records in the Netherlands, is encouraging. The authors report that more than one fourth of the 6400 Dutch general practitioners have instituted a computer-based clinical record system in their offices. We discuss the status and issues involved with the use of computer-based records in the United States in the context of the Dutch experience.

The diverse and heterogenous patterns of care and the various medical provider and institutional environments characteristic of U.S. health care have resulted in a fragmented patient medical record, with no single provider, institution, or third-party payer responsible for maintaining a comprehensive record. Consequently, the major thrust of the …