The patient record and the rise of the pediatric EHR

Standards and the Computerized Patient Record

PsycEXTRA Dataset ◽

10.1037/e308722004-003 ◽

2001 ◽

Author(s):

Theresa Cullen

Keyword(s):

Patient Record ◽

Computerized Patient Record

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A Generic Model of Clinical Practice

Methods of Information in Medicine ◽

10.1055/s-0038-1634245 ◽

2003 ◽

Vol 42 (03) ◽

pp. 203-211 ◽

Cited By ~ 5

Author(s):

J. L. G. Dietz ◽

A. Hasman ◽

P. F. de Vries Robbé ◽

H. J. Tange

Keyword(s):

Clinical Practice ◽

Theoretical Model ◽

Action Theory ◽

Human Subjects ◽

Shared Care ◽

Patient Record ◽

Generic Model ◽

Problem Solver ◽

Record Keeping ◽

Process View

Summary Objectives: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice. Methods: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations. Results: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR. Conclusions: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

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The Separation of Reviewing Knowledge from Medical Knowledge

Methods of Information in Medicine ◽

10.1055/s-0038-1634593 ◽

1995 ◽

Vol 34 (01/02) ◽

pp. 131-139 ◽

Cited By ~ 4

Author(s):

M. A. Musen ◽

J. van der Lei

Keyword(s):

Medical Knowledge ◽

Patient Record ◽

Patient Records ◽

Computer Based ◽

New Challenges ◽

Arden Syntax

Abstract:The developers of reviewing systems that rely on computer-based patient-record systems as a source of data need to model reviewing knowledge and medical knowledge. We simulate how the same medical knowledge could be entered in four different systems: CARE, the Arden syntax, Essential-attending and HyperCritic. We subsequently analyze how the original knowledge is represented in the symbols or syntax used by these systems. We conclude that these systems provide different alternatives in dealing with the vocabulary provided by the computer-based patient records. In addition, the use of computer-based patient records for review poses new challenges for the content of that record: to facilitate review, the reasoning of the physician needs to be captured in addition to the actions of the physician.

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Improving Coded Data Entry by an Electronic Patient Record System

Methods of Information in Medicine ◽

10.1055/s-0038-1634644 ◽

1996 ◽

Vol 35 (02) ◽

pp. 108-111 ◽

Cited By ~ 8

Author(s):

F. Puerner ◽

H. Soltanian ◽

J. H. Hohnloser

Keyword(s):

Phase I ◽

Electronic Patient Record ◽

Data Entry ◽

Discharge Summary ◽

Patient Record ◽

Phase Iii ◽

Electronic Patient Record System ◽

Record System ◽

Data Encoding ◽

Discharge Summaries

AbstractData are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may “shift” as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby “bypassing” the need to encode, this was reduced by up to 41 % with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.

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Computerization of the Patient History -Patient Answers Compared with Medical Records

Methods of Information in Medicine ◽

10.1055/s-0038-1635472 ◽

1986 ◽

Vol 25 (04) ◽

pp. 222-228 ◽

Cited By ~ 5

Author(s):

M. J. Quaak ◽

R. F. Westerman ◽

J. A. Schouten ◽

A. Hasman ◽

J. H. Bemmel

Keyword(s):

Internal Medicine ◽

Medical Records ◽

Patient Record ◽

Frequency Of Occurrence ◽

History Taking ◽

Patient History ◽

Patient Complaints ◽

Computerized Patient Record ◽

Extensive Information ◽

Experienced Physician

SummaryComputerized medical history taking, in which patients answer questions by using a terminal, is compared with the written medical record for a group of 99 patients in internal medicine. Patient complaints were analysed with respect to their frequency of occurrence for all important tracts, such as the respiratory, the gastro-intestinal and the uro-genital tracts. About 36% of over 3,200 patient answers were identical in the patient record and the written record, but a considerable percentage of complaints (56%), that were present in the patient record, were missing in the written record; the reverse was true for 4.5%. A computerized patient record appears to contain more extensive information about patient complaints, still to be interpreted by the experienced physician.

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