Electronic Patient Records in Medical Practice: A Multidisciplinary Endeavor

1999 ◽  
Vol 38 (04/05) ◽  
pp. 287-288 ◽  
Author(s):  
J. van der Lei ◽  
P. W. Moorman ◽  
M. A. Musen
2002 ◽  
Vol 41 (01) ◽  
pp. 51-54 ◽  
Author(s):  
J. van der Lei

Summary Objective: To discuss the possible contribution of electronic patient records in closing the loop among clinical practice, research and education. Results and conclusions: Applying Information and Communication Technology (ICT) to a given medical domain is not merely adding a new technique. When introduced into an environment, ICT will initially often emulate or resemble the already existing processes. When workers and researchers in that domain begin to appreciate the potential of ICT, this initial stage is followed by more fundamental changes in that domain that take advantage of the potential of ICT. To understand the scope of the potential changes enabled by electronic records, three principle changes need to be understood. First, data recorded in computer memories can be readily retrieved and re-used for a variety of purposes. Second, once data are available in computer memories, the data can be transported easily. Third, as physicians (and patients) are using computers to record medical data, the same electronic record can be used to introduce other computer programs that interact with the user. New usage of data, however, generates additional requirements. Thus the experience in developing decision support systems and analyzing observational databases feeds back into the requirements for electronic medical records.Each patient-physician encounter, each investigation, each laboratory test, and each treatment in medical practice constitutes, in principle, an experiment. Ideally, we learn from each experiment. Electronic medical records will facilitate research that relies on data recorded in routine medical practice. The potential and challenge, however, of Medical Informatics lies in its ability to close the loop among clinical practice, research, and education.


1999 ◽  
Vol 38 (04/05) ◽  
pp. 279-286 ◽  
Author(s):  
L. L. Weed

AbstractIt is widely recognised that accessing and processing medical information in libraries and patient records is a burden beyond the capacities of the physician’s unaided mind in the conditions of medical practice. Physicians are quite capable of tremendous intellectual feats but cannot possibly do it all. The way ahead requires the development of a framework in which the brilliant pieces of understanding are routinely assembled into a working unit of social machinery that is coherent and as error free as possible – a challenge in which we ourselves are among the working parts to be organized and brought under control.Such a framework of intellectual rigor and discipline in the practice of medicine can only be achieved if knowledge is embedded in tools; the system requiring the routine use of those tools in all decision making by both providers and patients.


1999 ◽  
Vol 38 (04/05) ◽  
pp. 339-344 ◽  
Author(s):  
J. van der Lei ◽  
B. M. Th. Mosseveld ◽  
M. A. M. van Wijk ◽  
P. D. van der Linden ◽  
M. C. J. M. Sturkenboom ◽  
...  

AbstractResearchers claim that data in electronic patient records can be used for a variety of purposes including individual patient care, management, and resource planning for scientific research. Our objective in the project Integrated Primary Care Information (IPCI) was to assess whether the electronic patient records of Dutch general practitioners contain sufficient data to perform studies in the area of postmarketing surveillance studies. We determined the data requirements for postmarketing surveil-lance studies, implemented additional software in the electronic patient records of the general practitioner, developed an organization to monitor the use of data, and performed validation studies to test the quality of the data. Analysis of the data requirements showed that additional software had to be installed to collect data that is not recorded in routine practice. To avoid having to obtain informed consent from each enrolled patient, we developed IPCI as a semianonymous system: both patients and participating general practitioners are anonymous for the researchers. Under specific circumstances, the researcher can contact indirectly (through a trusted third party) the physician that made the data available. Only the treating general practitioner is able to decode the identity of his patients. A Board of Supervisors predominantly consisting of participating general practitioners monitors the use of data. Validation studies show the data can be used for postmarketing surveillance. With additional software to collect data not normally recorded in routine practice, data from electronic patient record of general practitioners can be used for postmarketing surveillance.


2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Marina Beckmann ◽  
Kerstin Dittmer ◽  
Julia Jaschke ◽  
Ute Karbach ◽  
Juliane Köberlein-Neu ◽  
...  

Abstract Background The need for and usage of electronic patient records within hospitals has steadily increased over the last decade for economic reasons as well as the proceeding digitalization. While there are numerous benefits from this system, the potential risks of using electronic patient records for hospitals, patients and healthcare professionals must also be discussed. There is a lack in research, particularly regarding effects on healthcare professionals and their daily work in health services. The study eCoCo aims to gain insight into changes in interprofessional collaboration and clinical workflows resulting from introducing electronic patient records. Methods eCoCo is a multi-center case study integrating mixed methods from qualitative and quantitative social research. The case studies include three hospitals that undergo the process of introducing electronic patient records. Data are collected before and after the introduction of electronic patient records using participant observation, interviews, focus groups, time measurement, patient and employee questionnaires and a questionnaire to measure the level of digitalization. Furthermore, documents (patient records) as well as structural and administrative data are gathered. To analyze the interprofessional collaboration qualitative network analyses, reconstructive-hermeneutic analyses and document analyses are conducted. The workflow analyses, patient and employee assessment analyses and classification within the clinical adoption meta-model are conducted to provide insights into clinical workflows. Discussion This study will be the first to investigate the effects of introducing electronic patient records on interprofessional collaboration and clinical workflows from the perspective of healthcare professionals. Thereby, it will consider patients’ safety, legal and ethical concerns and quality of care. The results will help to understand the organization and thereby improve the performance of health services working with electronic patient records. Trial registration The study was registered at the German clinical trials register (DRKS00023343, Pre-Results) on November 17, 2020.


Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Sophie Relph ◽  
◽  
Maria Elstad ◽  
Bolaji Coker ◽  
Matias C. Vieira ◽  
...  

Abstract Background The use of electronic patient records for assessing outcomes in clinical trials is a methodological strategy intended to drive faster and more cost-efficient acquisition of results. The aim of this manuscript was to outline the data collection and management considerations of a maternity and perinatal clinical trial using data from electronic patient records, exemplifying the DESiGN Trial as a case study. Methods The DESiGN Trial is a cluster randomised control trial assessing the effect of a complex intervention versus standard care for identifying small for gestational age foetuses. Data on maternal/perinatal characteristics and outcomes including infants admitted to neonatal care, parameters from foetal ultrasound and details of hospital activity for health-economic evaluation were collected at two time points from four types of electronic patient records held in 22 different electronic record systems at the 13 research clusters. Data were pseudonymised on site using a bespoke Microsoft Excel macro and securely transferred to the central data store. Data quality checks were undertaken. Rules for data harmonisation of the raw data were developed and a data dictionary produced, along with rules and assumptions for data linkage of the datasets. The dictionary included descriptions of the rationale and assumptions for data harmonisation and quality checks. Results Data were collected on 182,052 babies from 178,350 pregnancies in 165,397 unique women. Data availability and completeness varied across research sites; each of eight variables which were key to calculation of the primary outcome were completely missing in median 3 (range 1–4) clusters at the time of the first data download. This improved by the second data download following clarification of instructions to the research sites (each of the eight key variables were completely missing in median 1 (range 0–1) cluster at the second time point). Common data management challenges were harmonising a single variable from multiple sources and categorising free-text data, solutions were developed for this trial. Conclusions Conduct of clinical trials which use electronic patient records for the assessment of outcomes can be time and cost-effective but still requires appropriate time and resources to maximise data quality. A difficulty for pregnancy and perinatal research in the UK is the wide variety of different systems used to collect patient data across maternity units. In this manuscript, we describe how we managed this and provide a detailed data dictionary covering the harmonisation of variable names and values that will be helpful for other researchers working with these data. Trial registration Primary registry and trial identifying number: ISRCTN 67698474. Registered on 02/11/16.


2012 ◽  
Vol 30 (2) ◽  
pp. 227-232 ◽  
Author(s):  
F. Stevenson ◽  
N. Lloyd ◽  
L. Harrington ◽  
P. Wallace

2012 ◽  
Vol 94 (4) ◽  
pp. 128-130
Author(s):  
Sac MacKeith ◽  
Svelusamy ◽  
A Pajaniappane ◽  
P Jervis

Doctors' handwriting has long been criticised as being difficult to read or even illegible. In more recent years research has confirmed that it is not uncommon to find medical case note entries that are deficient, illegible or unidentifiable. In Good Medical Practice the General Medical Council (GMC) asks that doctors 'keep clear, accurate, legible and contemporaneous patient records'. In addition, the GMC 'expects that all doctors will use their reference numbers widely to identify themselves to all those with whom they have professional contact'. This includes encouragement for its use in case note entries and prescribing.


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