Module Information

Getting the electronic patient record or the electronic health record `right? is as much an organisational issue as a technical issue, although some innovative technology will help resolve some of the organisational problems. Unit 1 of the module examines how clinical information and clinical knowledge are actually used in clinical decision making. We need to consider first how health professionals structure their knowledge and apply that knowledge before we can understand how the electronic record might be used (or not used) in professional practice. That discussion of clinical decision support leads into Unit 2 which deals with the languages used for clinical communication and `archiving? of clinical knowledge - the coding and classification schemes which underpin the record. The structure and the architecture of the electronic patient record are discussed in Unit 3. For the purposes of the module the generic term `electronic patient record? is used for most of the discussion, although much of the module relates to the development of the longitudinal summary record, the electronic health record for an individual patients. Individuals are likely to have highly personal and sensitive information held in their records. Some of that information they may be willing to share with some health professionals under certain conditions. Some of that information they might not want friends or acquaintances or `prying eyes? to see under any circumstances. While we may seem less concerned about personal privacy than many predicted, our health records are different from our bank records, and confidentiality is a concern, particularly when it could be so easy to gain access to someone else'r electronic patient records. Unit 4 covers the confidentiality and security concerns, and the technical implications. Unit 5 discusses some of the applications of the patient record, and considers, for example, studies of various types of shared record - the patient-held record, for example. The implications of a systematic review of nursing record systems are considered as that considered the effect on professional practice and patient outcomes of attempts to make the recording more structured. Some of the difficulties highlighted in the review are reflected in Unit 6, which examines some of the case studies of electronic patient record implementation, and some of the trials, such as the ERDIP project in the UK, and the MARS system developed by Kaiser Permanente in the USA.