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At this very moment, health care

worldwide is experiencing the onslaught
of new paradigms:
1. Evidence-Based Medicine
2. Medical Education
3. Technological Change
4. Evolving Standards of Care
5. Changing Roles of Traditional Stakeholders
6. Globalization
 Escalating costs approaching $1 trillion in
the 1990s have triggered a call from various
stakeholders in health care for mechanisms to
curb unwanted expenses, bad debts and
inefficient health care delivery systems. Health
care continues to evolve as it is driven by
market-driven forces, alliances and mergers, and
developments in software and hardware
technology bringing about cost-efficient
deployment of information systems. This
evolution will surely continue to push
developments in CPR systems to the limits.
 Managed care has shifted several aspects of care
delivery such as (1) underlining the importance of primary care
providers as gatekeepers to specialty care and special diagnostic
tests, and (2) transferring more of the care outside of the
hospital (Ambulatory care). Alliances and mergers have resulted
in the integrated delivery of services, thereby streamlining the
procedural aspects of obtaining health care into a seamless,
comprehensive entity. This has opened possibilities for more
comprehensive assessments and evaluation of the quality of care
and hence, higher level organization and development of
standards of care. Developments in computer hardware and
sotfware occuring at blazing speeds, together with widespread
connectivity through local area and wide area networks and the
Internet have brought about (1) new tools with which to enable
care providers to have access to huge, untapped information
resources, and (2) the possibility of accessing patient records
from anywhere in the world and from a variety of platforms of
hardware and software.
 Having these developments at hand, the concept of a
CPR system has evolved to include five important
ingredients characteristic of functional needs of its end-
users, in particular:

È Integrated view of patient data

È Access to knowledge resources (guidelines, rules,
regulations, medical literature)
È Physician order entry and clinician data entry
È Integrated communications support
È Clinical decision support (drug interaction and
abnormal laboratory test alerts, trend analysis,
matching to clinical practice guidelines, critiquing
systems)
 At the present stage of development,
CPR systems are being adopted by only
few health care institutions
considering that the driving forces for
its adoption are already existent and
the continued use of paper-based
systems are becoming more non-
viable.
 
 


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 There are 5 conditions identified by the IOM

study committee that will contribute to the
success of CPR systems:
È The uses of and demands for patient data are growing. Health services
research and the increased focus on content and value of therapies are a
source of push in this direction.
È We now have more powerful and affordable technologies brought about
by economies of scale in utilization and production of IT products.
È Computers inadvertently increase efficiency in virtually all aspects of
everyday life.
È The increasing mobility of Americans, the increase in the patient
population with chronic diseases, the connectivity of open systems and
interoperable network systems provide a ripe environment for managing
large amounts of information over geographic and political boundaries.
È Reform in health care to make it more responsive to patient needs, as well
as, more manageable financially and organizationally requires automation
records management.
The IOM study committee also identified 5
objectives for future CPR systems. CPR
systems should:
È Support patient care and improve its quality
È Enhance productivity of health care professionals
and reduce administrative costs associated with
health care delivery and financing
È Support clinical and health services research
È Accommodate future developments in health
care technology, policy, management and finance
È Have mechanisms in place to ensure patient data
confidentiality at all times
If users are to derive maximum benefit from the
use of CPR systems, they must satisfy the
following conditions:
È They must have confidence in the data.
È They must use the data actively in the clinical
setting.
È They must have the orientation that what they
are using is not just a repository of patient data
but a whole new resource combining tools that
will enable them, for example, to get additional
information, or make better decisions.
È They must be proficient in the use of these CPR
systems as well as the tools referred to above.
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Development of a patient care information
systems should be viewed more as a
journey rather than a specific
destination. Being a journey, the patient
care information system strategy now
serves as a  
 containing both the
theoretical (conceptual design) and
practical (technical, functional and
operational design) aspects. This road
map should contain the following:
 Conceptual overview
s Vision statement - theoretical framework, explains
the intent of the IS
s principles that govern the IS - maybe theoretical
or precise, links institutional objectives with IS
direction, also describes what the IS 
 
s Assumptions - assists in describing the
organizational model and the environment in
which it functions, as well as the interfaces and
the potential problems
 üunctional strategy
s Generic clinical functions of the organization
s Specific clinical functions grouped by categories
s üunctional model - shows interrelationships among
application areas and its current level of development
(not automated, moderately supported, well
supported)
s Operational prerequisites - must be in place before IS
implementation
s Support role view - how new and existing applications
support key patient care delivery roles
 Technical strategy
s Overview of technical environment - should be conducive
for both novice and experienced system user
s Technical characteristics of the infrastructure
s Technical standards (e.g., HL-7)
s Integration considerations - particularly for heterogeneous
systems and scalability and ability to integrate different ISs
in the future
s Evaluation criteria (ability to meet functional user
requirements, availability for access, performance
characteristics, technical resource consumption, business
resumption considerations, cost)
s Principles - flexible, open standards
 Acquisition strategy
s Well-defined and thorough process, considering long-term
potential
s Principles: enhance value of IS to physicians, maintain stable
operating environment
s Ground rules for in-house development and outside sourcing
s Selection criteria for outside sourcing: functional integration,
independent and relative functionality, growth in volume and
functionality, closeness to technical strategy, level of complexity,
historical vendor performance, technical vendor support,
vendor's projected stability for the next 5 years
s Guidance regarding use of organization as test site for vendor
products (risk, frustration of users)
s References to organization's system development methodology
 Migration strategy
s Sequence of and processes for application
implementation
s Discrete project tasks (infrastructure building, new
application systems implementation, organizational
changes), task prioritization and risk assessment
(technical, functional, implementation risks) for each
task
s Risk assessment based on: evaluation of stage of
development of technology, information collected for
functional and technical plans and experiences of
other institutions regarding same projects
s Minimize new capital investment
Operational and maintenance strategy
s Evaluation of utilization
s Improvements in IS with changes in health care
delivery processes, enhancements to clinician
interaction (voice-processing) and technological
developments
s Approaches to dealing with system maintenance:
application of software releases when functionally
stable, release concept of modifications and
enhancements
s Responsibilities of the user, managers and vendors
s Concept of operations - changes to be anticipated in
operations once system is implemented
 Implications/Impact
s Management concerns
s Implications: "sum-of-parts" system (view of
totality), "ownerless" system (concerted
management), precedence over grassroots efforts
(to provide wholeness)
 c  
c

  
 Coding of medical data is done for the following reasons: (1) data reduction, (2)
standardization of terminology, (3) enabling research, (4) support of management and
planning, (5) coupling with decision support systems and knowledge sources. In the
process of 

  , we create an 



  
within a domain
using ordering principles. A domain could be any of the following: reason for
encounter (RüE), diagnosis, medical procedure, or it could be any other concept
related to patient care and to the patient himself. Classifications can use one or more

, which are usually any of the following: anatomic location,
etiology, morphology and dysfunction. Each ordering that we make using one principle
is called an 
. A 

is a list of terms used for a certain domain, should be
complete for every domain and should contain a list of
 

for each term. In a

 , codes are assigned\ to medical concepts and these, then, can be
combined to form other concepts (compare with classification where codes are
predefined for all possible conditions). In classifications, classes are defined by codes.
c  is the interpretation of the aspects of an object and are formed using numbers,
letters or both. Codes are of the following types: number, mnemonic , hierarchical
(parent-child), juxtaposition (segments), combination (medical procedure codes), and
value addition codes (powers of 2). Two more terms deserve mention here and these
are   
, the theoretical study of classification or the science of classification,
and 
 , the science of classification of diseases, or more specifically, diagnostic
terms. See Table 4 for Classifications and Nomenclature.