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A powerful macro-model for the computer patient record
A M van Ginneken1, H Stam, J S Duisterhout
1Department of Medical Informatics, Erasmus University, Rotterdam, The Netherlands.
Proceedings. Symposium on Computer Applications in Medical Care
|January 1, 1994
Summary
This study introduces a computer patient record (CPR) system designed for specialists, balancing conventional record-keeping with data structuring to improve clinical data usability.
Area of Science:
- Medical Informatics
- Health Information Technology
- Clinical Systems Design
Background:
- Computer patient records (CPRs) have seen success in primary care.
- Specialized care presents unique challenges for CPR design due to extensive record-keeping needs.
Purpose of the Study:
- To present the design of a novel CPR system tailored for specialists in out-patient clinics.
- To develop a system that encourages data structuring while accommodating conventional specialist record-keeping practices.
Main Methods:
- The CPR system design emphasizes flexibility, allowing specialists to maintain records conventionally.
- It incorporates features to motivate data structuring and presents data in task-specific views.
- The system supports explicit representation of observations and the evolution of insights for data fidelity.
Main Results:
- The CPR system is in the final stages of implementation.
- An upcoming clinical evaluation in summer 1994 will assess its practical utility.
Conclusions:
- The designed CPR system aims to enhance the utility and practicality of electronic health records for specialized medical care.
- Successful implementation and evaluation are anticipated to demonstrate the system's benefits in structuring clinical data.