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Related Experiment Videos

Computerized medical records: defining a standard without the computer.

A R Bradbury1

  • 1USAF Hospital Altus/SGHF, Altus AFB, OK 73523-5300.

Medical Informatics = Medecine Et Informatique
|July 1, 1991
PubMed
Summary

Computerizing medical records offers benefits but requires careful planning. A proposed structure for electronic medical records (EMR) prioritizes independence from technology, ensuring flexibility and defining roles for successful implementation.

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Area of Science:

  • Medical Informatics
  • Health Information Systems
  • Computer Science in Healthcare

Background:

  • The increasing computerization of medical records presents both opportunities and challenges for healthcare.
  • A successful transition requires a comprehensive understanding of the project and clear objectives.

Purpose of the Study:

  • To propose definite goals for the computerized medical record.
  • To advocate for a medical record structure independent of specific technological constraints.
  • To define the roles of various stakeholders in the computerization process.

Main Methods:

  • Presenting an argument for decoupling medical record structure from technology requirements.
  • Proposing an elegant, technology-agnostic structure for medical records.

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  • Defining the roles and responsibilities of clinical specialists, medical records specialists, administrators, accountants, and computer architects.

    • Main Results:

    • An elegant medical record structure is proposed, minimizing definitions and special characters.
    • Clear roles are defined for all involved parties, including physicians, nurses, and IT professionals.
    • The critical and ongoing nature of lexicon and template creation is emphasized.

    Conclusions:

    • A successful computerization of medical records necessitates a well-defined, technology-independent structure.
    • Collaboration and clearly defined roles among diverse stakeholders are crucial.
    • Urgent and continuous attention to lexicon and template development is vital for specialty organizations.