Editorial: Hitting a Moving Target: Toward a Compliance-driven Patient Record

ties. With each patient, every treatment event generates two pieces of information: a clinical record (notes, orders, and results generated by and for practitioners) and a billing record. The two are processed separately (most often in parallel; at times, serially). Integrating them yields the patient record. Current technology is based on the unintegrated historic record. Only when the patient leaves a treatment facility do a number of people/software systems start the reconciliation process—matching clinical information from the clinical record with charge information from the billing record to meet the requirements of Federal agencies and third-party payers. Incomplete compliance, discovered only after discharge, is difficult or impossible to resolve.