STANDARDS FOR MEDICAL IDENTIFIERS, CODES, AND MESSAGES NEEDED TO CREATE AN EFFICIENT COMPUTER-STORED MEDICAL RECORD

A major obstacle-to establishing a computer-stored medical record is t he lack of ''standards'' that would permit government, care providers, insurance companies, and medical computer system developers to share patient data easily. In this position paper, the Board of Directors or the American Medical Informatics Association recommends specific appr oaches to( )standardization in the areas of patient, provider, and sit e of care identifiers; computerized health care message exchange; medi cal record content and structure, and medical codes and terminologies. The key concept developed in this position paper is that developers a nd users of computer-stored medical records must embrace existing and tested approaches, despite their imperfections, to progress quickly. T his approach to standardization is being coordinated with the American National Standards Institute's Health Informatics Standards Planning Panel. The development of standards is a long-term process involving c ontinued refinement. The proposed standards are an important step towa rd the goal of better and more efficient health care.