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Computer-based patient record: the essential data set approach

K Moidu1, J J Falsone, S Nair

  • 1Beulah Hinds Center for Health Informatics, Section for Pulmonary and Critical Care Medicine, Norwalk Hospital, CT 06856.

Proceedings. Symposium on Computer Applications in Medical Care
|January 1, 1994
PubMed
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Developing computer-based patient record systems requires addressing clinical data variability and diverse user needs. This study proposes an infological data modeling approach for essential data set identification and implementation in physician offices.

Area of Science:

  • Health Informatics
  • Medical Informatics
  • Clinical Data Management

Background:

  • Increasing demand for clinical data to assess care impact, performance, and resource use.
  • Clinical encounter records are the primary source of needed data.
  • Information technology advances enable computer-based patient record (CPR) system development.

Purpose of the Study:

  • To describe an approach for developing a computer-based patient record system.
  • To focus on identifying an essential data set using infological data modeling.
  • To implement this data set in a physician's office software package.

Main Methods:

  • Infological data modeling to identify essential data elements.
  • Focus on the inherent variability and specialized nature of medical data.

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  • Implementation within a commercial software package for clinical practice.

    • Main Results:

    • A method for defining an essential data set for CPRs was developed.
    • The approach addresses challenges of medical data variability and diverse end-user needs.
    • Successful implementation in a physician's office setting was demonstrated.

    Conclusions:

    • Infological data modeling is effective for defining essential data sets in CPRs.
    • Addressing clinical data complexities is crucial for successful CPR implementation.
    • This approach facilitates better data utilization for clinical evaluation and resource management.