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Computerizing medical records: software criteria for systems to document patient encounters
Critical Care Medicine
|January 1, 1990
Summary
Designing effective computer systems for medical documentation is challenging. This study identified key software characteristics for successful clinical systems, leading to a physician-friendly electronic medical chart.
Area of Science:
- Health Informatics
- Software Engineering
Background:
- Developing computer systems for medical documentation by healthcare professionals presents significant challenges.
- Not all software development approaches are suitable for clinical documentation needs.
Purpose of the Study:
- To identify critical software characteristics for efficient development and effective clinical support in medical documentation systems.
- To develop and evaluate a computerized medical chart system based on these characteristics.
Main Methods:
- Identified 21 specific software characteristics crucial for clinical documentation systems.
- Developed a computerized medical chart system utilizing a software tool that met these identified characteristics.
- Focused on enabling physicians to write notes and document patient encounters efficiently.
Main Results:
- A successful computerized medical chart system was developed, allowing physicians to document patient encounters.
- The system's success was attributed to the alignment between the software's capabilities and the project's specific requirements.
- The developed criteria provide a foundation for evaluating similar software applications.
Conclusions:
- A well-chosen software approach is vital for creating efficient and usable clinical documentation systems.
- The identified software characteristics serve as a valuable guide for future development and evaluation of physician-input systems.
- Successful implementation hinges on the synergy between software capabilities and clinical workflow demands.
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