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Naming notes: transitions from free text to structured entry

J Gregory1, J E Mattison, C Linde

  • 1Department of Communication, University of California at San Diego, La Jolla, USA.

Methods of Information in Medicine
|March 1, 1995
PubMed
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Future healthcare requires robust information infrastructure. This study explores transitioning from handwritten to electronic health records, focusing on social science insights for system development and implementation.

Area of Science:

  • Health Informatics
  • Social Science Research
  • Medical Records Management

Background:

  • Current medical records practices lack essential information infrastructure for future healthcare.
  • The transition to electronic health records (EHRs) necessitates understanding system transformations.
  • Social science research offers insights into integrating new technologies into healthcare.

Purpose of the Study:

  • To establish a framework connecting medical informatics systems development with practical, cultural, and conceptual issues.
  • To guide the transition from free-text documentation to structured data entry for patient profiles.
  • To analyze the reciprocal modifications in EHR design and use through iterative prototyping.

Main Methods:

  • Social science research integrated into a multi-disciplinary R&D effort.

Related Experiment Videos

  • Iterative prototyping of an electronic health record system.
  • Study conducted within the Southern California Kaiser Permanente Medical Care Program's integrated delivery environment.

    • Main Results:

    • The study provides a framework for addressing challenges in EHR implementation.
    • It highlights the negotiation process between EHR design and user practices.
    • Findings inform the development of EHR prototypes for integrated healthcare settings.

    Conclusions:

    • Successful EHR adoption requires addressing practical, cultural, and conceptual challenges.
    • Iterative prototyping and multi-disciplinary collaboration are key to EHR development.
    • The research contributes to understanding the transformation of healthcare activity systems through informatics.