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Abstract:
Paper truncation may be the first goal that comes to mind when people think of computerized medical records, but this is probably the least realistic goal at present. Structuring a medical records system to improve record quality and to open the door to data analysis are two more realistic goals. Of the many significant barriers to computerized medical records, the most serious is the lack of agreement in the medical community regarding what should go into a medical record. Even small steps in that area should bring major improvements in available medical records software. Choosing a database for medical records requires familiarity with database principles and a detailed understanding of data needs. The safe choice is an SQL-based relational database, but a smaller system will suffice if present and future medical records challenges are small enough. The rate of change in the computer world is increasing all the time. Emerging and maturing technologies that can have a significant impact on medical records software include data entry tools such as the mouse, pen, and voice; better data retrieval tools such as GUIs and 4GLs; and software tools that use rules, pattern-matching, hypermedia links, and fuzzy logic to create systems that seem to think like humans. While computerized medical records systems are not yet comparable with medical office management systems, they should be someday. In the meantime, smart physicians will begin exploring possibilities on their own in order to reap some benefits at an early stage and to be better prepared when the tide finally turns.