Uniform Data Standards for Patient Medical Record Information. Report to theSecretary of the U.S. Department of Health and Human Services

摘要

High quality health care depends on complete and comprehensive patient medicalrecord information (PMRI). This information is essential to support diagnosis and treatment, measure and improve quality of care, advance public health, enhance healthcare productivity, and facilitate reimbursement. Today, however, patient medical record information is primarily written, stored, and transported on paper. This paper-based information is often illegible, subject to delays, difficult to interpret, frequently misplaced or lost, and contributes to unnecessary costs. While health care has adopted information technology for financial and administrative systems, it has made limited progress in utilizing information technology to support patient care. Today, the greatest impediment to the adoption of information technology is the lack of complete and comprehensive standards for patient medical record information.