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Towards unambiguous representation of patient data
A M van Ginneken1, J van der Lei, P W Moorman
1Dept. of Medical Informatics, Erasmus University, Rotterdam, The Netherlands.
Proceedings. Symposium on Computer Applications in Medical Care
|January 1, 1992
Summary
Computer-based patient records (CBPRs) are useful for care but limited for secondary uses. Research explores inferring implicit information from CBPRs using concept knowledge to minimize physician effort.
Area of Science:
- Medical Informatics
- Health Information Systems
- Clinical Documentation
Background:
- Early computer-based patient records (CBPRs) aimed to replicate paper records, proving effective for direct patient care.
- While successful in clinical practice, these paper-like CBPRs present challenges for secondary data analysis and research.
- Physician time constraints limit their ability to provide extensive additional data for unambiguous record interpretation.
Purpose of the Study:
- To investigate methods for extracting maximum value from CBPRs with minimal physician input.
- To explore the potential of leveraging conceptual knowledge within patient records to infer implicit information.
- To address the limitations of current CBPRs in supporting secondary data use.
Main Methods:
- Analysis of existing CBPR strategies and their suitability for secondary data utilization.
- Focus on inferring implicit patient data through knowledge about concepts within the record.
- Consideration of strategies to balance information elicitation with physician effort.
Main Results:
- Paper-like CBPRs are insufficient for reliable secondary data use due to ambiguous interpretation.
- Physicians' general knowledge aids inferences, but explicit patient data is often lacking for broader applications.
- Inferring implicit information using conceptual knowledge offers a promising avenue.
Conclusions:
- Rethinking CBPR design is necessary to support both direct care and secondary data analysis.
- Strategies that infer information based on existing data and conceptual knowledge are crucial.
- Minimizing physician effort while maximizing data utility is key for successful CBPR implementation.