Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Medical Records Systems, Computerized”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 91 records · Page 5Linked to original sources
PubMed2001

Dynamic viewer of medical events in electronic medical record.

Medical record should enable doctors to comprehend the patient's history and select suitable medical treatment. In paper based medical records, medical events (examination, treatment etc.) are recorded successively, and problem oriented recording is difficult to be applied to patients with much information and a long history. Consequently it is not easy to understand the patient's history from paper based medical records. In order to solve this problem, we developed the flow sheet system in our electronic medical record (EMR). To make a flow sheet, we analyzed the structure of the medical event data. In this paper we introduced the medical event information model for our EMR. Furthermore, we clarified the specification of the data presentation on the flow sheet. We developed the flow sheet on the basis of these analyses. Because there are 3 layers in the vertical axis of the flow sheet, many items of the medical event can be displayed on the screen. When user clicks the cell, the corresponding detail data including images are shown. This system functions to link medical event items with a problem, and shows the bundled items on the flow sheet when the user selects the problem. We implemented this system in Osaka University Hospital. The number of the types of medical events and those of detail events in inpatients are 5.0+1.7 (mean+SD) and 60+47, respectively. The medical doctors in Osaka University Hospital evaluated this system, and concludes that the flow sheet data presentation makes comprehension of the patient's history easier than paper based records. As to the function of bundling the items relevant to the problem, they feel it is especially useful for patients with chronic disease. Thus the flow sheet data presentation in EMR is useful for medical practice.

Chronic Disease↗
PubMed2001

Toward a model for the evaluation of clinical coding systems.

OBJECTIVE: To demonstrate an empirical method to evaluate the utility of clinical coding systems. To use this method to assess the predictive power of two codes. METHOD: Controlled trial of two coding systems. SETTING: The Read Clinical Codes, version II and the International Classification of Primary Care (ICPC). OUTCOME MEASURES: The association between codes and pharmaceuticals prescribed. RESULTS: The power of both codes to predict pharmaceuticals increased with their precision. ICPC performed better than Read at the same level of precision. CONCLUSION: ICPC may be a more efficient coding system to use than Read. Assessment of the predictive power of a code is central to assessing its utility.

Diagnosis-Related Groups↗
PubMed2002

The index as a new concept towards an integrated framework for the electronic patient record.

OBJECTIVE: To overcome some classical limitations of the POMR (Problem-Oriented Medical Record), including the management of divergent opinions between health professionals, in order to construct a common patient record across multiple disciplines in hospital settings and professional networks. METHODS: Using a complex clinical case, we improved a POMR model previously used by GPs in order to translate it into a hospital setting. The enhanced model has been assessed through use in various ongoing clinical cases and through extended discussion with professional end-users (physicians, nurses, general practitioners, and social workers). RESULTS: The Index concept (flexible structural link) is proposed as a major improvement in the construction of a POMR in a shared care environment. CONCLUSIONS: The Index introduces interesting new perspectives. Following its implementation in the Belgian pilot site in the CORINES project, further studies remain to be carried out in order to develop a cost/benefit assessment.

Humans↗
PubMed2003

A generic model of clinical practice.

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.

Communication↗
PubMed1992

A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.

Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.

Humans↗
PubMedDate not supplied

Computerized medical records in family medicine journals, 1981-1990: diffusion of an innovation.

This study examined whether references to computerized medical records in family medicine journals had increased over the past decade as an example of diffusion of innovations. The abstract and methods sections of articles in Family Medicine, the Journal of Family Practice, and the Journal of the American Board of Family Practice were reviewed from 1981 to 1990 for explicit references to computerized medical records. The proportion of articles citing computerized medical records did not significantly increase overall or in any one journal during this time. Articles referenced computerized medical records with regard to sample selection for research studies (54%), description of computerized medical record systems (26%), and generation of health maintenance reminders (4%). These results are discussed in the context of family medicine literature and in terms of factors that typically impede the diffusion of innovations.

Diffusion of Innovation↗
PubMed1991

[Electronic data processing assisted documentation of tumor after care in an ambulatory setting--a simplification of daily routine].

A data collection system on microcomputer was developed for patients with malignant diseases in ambulant aftercare. At the same time when patient data are collected to be sent to a central medicostatistical plotting station, as it is usual in Austrian hospitals, a file for further aftercare is opened. By data transfer to other software products, statistical data evaluation is possible. Patients can also be called to hospital for different reasons.

Aftercare↗
PubMed1991

Non-categorical problem lists in a primary-care information system.

An ambulatory-care patient-tracking system has been implemented that records non-categorical problem descriptions in the outpatient problem list. The system does not restrict physicians to the use of predefined diagnostic categories. Instead, the system stores patient problems in a database as free-text records. Subsequent diagnostic categorization and coding is accomplished through prompted free-text input and appropriate reference databases. This system design allows an outpatient problem-list summary to reflect non-categorical health-status information in addition to coded medical diagnoses.

Ambulatory Care Information Systems↗
PubMed1991

Incorporating client-server database architecture and graphical user interface into outpatient medical records.

Computerized medical record systems require structured database architectures for information processing. However, the data must be able to be transferred across heterogeneous platform and software systems. Client-Server architecture allows for distributive processing of information among networked computers and provides the flexibility needed to link diverse systems together effectively. We have incorporated this client-server model with a graphical user interface into an outpatient medical record system, known as SuperChart, for the Department of Family Medicine at SUNY Health Science Center at Syracuse. SuperChart was developed using SuperCard and Oracle SuperCard uses modern object-oriented programming to support a hypermedia environment. Oracle is a powerful relational database management system that incorporates a client-server architecture. This provides both a distributed database and distributed processing which improves performance.

Ambulatory Care Information Systems↗
PubMed1991

Foundations for an electronic medical record.

Given the many efforts currently under way to develop standards for electronic medical records, it is important to step back and reexamine the fundamental principles which should underlie a model of the electronic medical record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it be a faithful record of what clinicians have heard, seen, thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed's Problem Oriented Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.

Decision Making↗
PubMed1990

[Text, archiving, coding--integration with electronic data processing].

For a successful computer-installation in the medical area you need a staff, which is used to work with computers in the daily routine. We tried with this project to establish the computer in a medical office by doing the whole patient-related writings on a specially tailored software. Most of the daily routine can now be done with the help of the computer. A certain time-saving effect could be achieved, although this was not our first aim. On this base we are now able to solve other problems such as coding, statistics or archiving routines by using our established computer environment.

Archives↗
PubMed1990

[Registration of detailed data in the medical record or how to translate "impressions" into measurable observations].

Every medical case record represents a mass of data (texts, pictures, figures, etc.) in an unstructured form. The physician needs to retrieve this data via several access routes: temporal (dependent on date or sequences of events), type of data (diagnostic, treatment, clinical signs, laboratory findings, image descriptors, all with their interrelationships), or depending on the severity of the disease, etc. Retrieval of this data fulfils several functions: circulation of a case record among specialists, assistance in summarizing a long and complex clinical course, comparison of patients, research, and teaching. Three projects are described which have the same aim: structuring of the case record in order to retrieve detailed data on patients as individuals and describe clinical courses on the basis of measurable observations. This structure must be understandable to a computer (directly or indirectly) so that searches and comparisons can be performed automatically. The first project, entitled "indexed paragraph prototype" reproduces the structure of the problem-oriented case record and is designed to input the Medical Outpatients Department's follow-up notes into the computer. The second, "automatic language analysis", aims to exploit two characteristics of medical language, its omnipresence in the case record and its reliability, in view of its status as the spontaneous vehicle of communication between physicians. The third, "collection of clinical signs during consultation", is based on a prospective collection of all elements of clinical observation, structured temporally consultation by consultation. The purpose of precise collection of detailed and measurable observations in individual patients is to identify those among the clinical signs which display the greatest power of discrimination, i.e. those which best serve to predict the case's evolution.

Abstracting and Indexing↗
PubMed1994

Are referring physicians satisfied with endoscopy reports?

To assess the opinions of referring physicians on the contents of endoscopy reports, 150 consecutive endoscopy reports were accompanied by a questionnaire. Of these, 102 reports were returned: response was 68%. Almost half of the reports were considered not fully satisfactory. However, endoscopy reports may be improved by including information such as indication, therapy plan and follow-up plan on a more regular basis, and add clarity whether findings may account for complaints of the patient. To tailor endoscopy reports to the needs of individual referring physicians, more explicit information of referring physicians is required. If endoscopists are responsible for the information they provide to the referrer, it is also their task to facilitate the explicit formulation of preferences by the referrer.

Attitude of Health Personnel↗