Automated Medical Records:

Leadership Needed to Expedite Standards Development

IMTEC-93-17: Published: Apr 30, 1993. Publicly Released: Jun 1, 1993.

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Pursuant to a congressional request, GAO reviewed the lack of comprehensive standards to ensure uniform electronic recording and transmission of medical information, focusing on: (1) standards needed to develop and share automated medical records; (2) the status of standards development; and (3) the federal role in developing standards.

GAO found that: (1) standards are crucial to sharing automated medical records due to the complex nature of modern health care and the need for a high degree of security and confidentiality; (2) vocabulary, structure and content, messaging, and security standards are needed for the effective exchange of medical information; (3) the health care community has developed only limited standards over the last 10 years, with the greatest progress in messaging standards; (4) the health care community has formed the Health Care Informatics Standards Planning Panel (HISPP) to coordinate standards development activities; (5) the lack of leadership to establish priorities, marshal resources, coordinate activities, and facilitate consensus-building has hindered standards development; (6) the federal government has played a minimal role in developing automated records standards because it relies on voluntary standards development organizations where feasible; (7) the Agency for Health Care Policy and Research (AHCPR) has the responsibility for developing automated medical records standards, but is reluctant to take its leadership role in the development process; (8) AHCPR has sponsored meetings on linking public and private medical data, funded research, and provided organizational support to HISPP; (9) other federal agencies that use medical records have participated in standards development with voluntary organizations in order to provide input on their mission needs; and (10) the Health Care Financing Administration has helped draft legislation that addresses its needs, sets standards priorities, sets target dates for certain standards to be in place, and requires hospitals to submit data electronically.

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