Carpenter PC. The electronic medical record: perspective from Mayo Clinic. Int J Biomed Comput (GQQ), 1994 Jan; 34 (1-4): 159-71.
Gouveia-Oliveira A; Lopes L. Formal representation of a conceptual data model for the patient-based medical record. Proc Annu Symp Comput Appl Med Care (BGL), 1993; 466-70.
van der Lei J; Duisterhout JS; Westerhof HP; van der Does E; Cromme PV; Boon WM; van Bemmel JH. The introduction of computer-based patient records in The Netherlands [see comments] Ann Intern Med (5A6), 1993 Nov 15; 119 (10): 1036-41.
Nagey DA; Blackman JA; Wright JN. The general medical record. Concepts and suggestions for implementation. Ann N Y Acad Sci (5NM), 1992 Dec 17; 670 109-15.
Rector AL; Nowlan WA; Kay S; Goble CA; Howkins TJ. A framework for modelling the electronic medical record. Methods Inf Med (MVI), 1993 Apr; 32 (2): 109-19.
van Ginneken AM; van der Lei J; Moorman PW. Towards unambiguous representation of patient data. Proc Annu Symp Comput Appl Med Care (BGL), 1992; 69-73.
Bishop CW. A new format for the medical record. MD Comput (MDC), 1991 Jul-Aug; 8 (4): 208-15.
RECORD NO.: 94305602 AUTHOR: Hartz AJ; Sigmann P; Guse C; Hagen TC ADDRESS: Family and Community Medicine, Medical College of Wisconsin, Milwaukee 53226. TITLE: The value of the Uniform Clinical Data Set System (UCDSS) in a hospital setting. SOURCE: Jt Comm J Qual Improv (BV3), 1994 Mar; 20 (3): 140-51 LANGUAGE: English COUNTRY PUB.: UNITED STATES ANNOUNCEMENT: 9410 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: BACKGROUND: The Health Care Financing Administration designed the Uniform Clinical Data Set System (UCDSS) to help peer review organizations (PROs) identify problems with patient care. The system currently is being piloted in five states and may be used for the PRO review of Medicare patients from all states by January 1995. This study tested whether UCDSS could be used with modifications for effective internal hospital quality review. METHODS: The UCDSS includes a computer program for collecting information from the medical record and 359 computerized algorithms that evaluate quality of care. For this study, 2,313 randomly chosen medical records from a tertiary care teaching hospital were abstracted with the UCDSS at the time of discharge. Cases flagged by the UCDSS algorithms as having potential quality-of-care problems were referred to a clinical reviewer to evaluate whether the flag was a true positive and to identify reasons for false-positive flags. The algorithms were modified based on this hospital's experience by adding the reasons for false-positive flags as exceptions to the algorithm rules. RESULTS: To abstract the data with the UCDSS required a median time of 45 minutes and a mean time of 55 minutes per medical record. The percentages of algorithm flags that were confirmed upon physician review to have a quality problem were estimated to be 21% for the UCDSS and 43% for the modified UCDSS. The confirmed problem rate varied substantially by algorithm. Confirmed problems were the source of numerous departmental and individual discussions and led to changes in five departmental procedures. CONCLUSIONS: Although the results of this study are preliminary and require further verification, they suggest that with modifications and careful attention to implementation, the UCDSS may be an expensive but potentially useful tool for in-hospital quality review. In-hospital employment of the UCDSS offers more opportunities for practical use of algorithms for continuous quality improvement rather than the sometimes punitive use of system findings by PROs. MESH HEADINGS: *Abstracting and Indexing; *Algorithms; *Hospital Information Systems; *Professional Review Organizations; Quality Assurance, Health Care--organization & administration (*OG); Adult; Aged; Evaluation Studies; Hospital Bed Capacity, 100 to 299; Hospitals, Teaching-- organization & administration (OG)/standards (ST); Middle Age; Reproducibility of Results; Research Design; Time Factors; United States; United States Health Care Financing Administration; Wisconsin; Female; Human; Male; Support, Non- U.S. Gov't STANDARD NO.: 1070-3241 DATES: Entered 940816 RECORD NO.: 94171392 AUTHOR: Carpenter PC ADDRESS: Mayo Foundation, Rochester, MN 55905. TITLE: The electronic medical record: perspective from Mayo Clinic. SOURCE: Int J Biomed Comput (GQQ), 1994 Jan; 34 (1-4): 159-71 LANGUAGE: English COUNTRY PUB.: IRELAND ANNOUNCEMENT: 9406 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: On 1 January 1993, the Electronic Medical Record Task Force at Mayo Clinic published its report. Charged by the Mayo Foundation to define the Electronic Medical Record (EMR) for Mayo, the task force mapped the goals, strategies and time- lines for implementation of the EMR in that institution. The task force was composed predominantly of caregivers (physicians and nurses) with assistance from members of Mayo's information systems and administrative departments. The focus of the effort was care of the patient with the consensus belief that the EMR will improve that process and, if designed robustly, will serve the other information needs of claims, research, education and practice management. The recommendations of this report have been accepted by the Mayo Foundation leadership resulting in the generation of a master plan and the creation of the governance structure for implementation at Mayo. This paper abstracts key portions of the report. MESH HEADINGS: *Hospitals, Group Practice; *Medical Records Systems, Computerized; Computer Systems; Data Display; Database Management Systems; Delivery of Health Care; Integrated Advanced Information Management Systems; Management Information Systems; Minnesota; Software; User-Computer Interface; Human STANDARD NO.: 0020-7101 DATES: Entered 940414 RECORD NO.: 94176865 AUTHOR: Gouveia-Oliveira A; Lopes L ADDRESS: Dept. Biomatematica, Faculdade de Medicina de Lisboa, Portugal. TITLE: Formal representation of a conceptual data model for the patient-based medical record. SOURCE: Proc Annu Symp Comput Appl Med Care (BGL), 1993; 466-70 LANGUAGE: English COUNTRY PUB.: UNITED STATES ANNOUNCEMENT: 9406 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: We present a general architecture for the patient-based medical record as it is being developed for the SAMS, a private social security system. The conceptual data model is described in a convenient formal notation, the entity- relationship diagram. Although following the original formulation of the problem-oriented medical record (POMR), the data model was designed with a level of generalization that, functionally, makes structural differences between conventional and POMR no longer apparent. The main features of this model are its adaptability to individual work practices and its problem-oriented structure, including the representation of problems' evolution. This structure will enable physicians to organize the data, mostly collected elsewhere, by explicitly relating the facts that constitute a particular patient record, which is a simple way to store context information and clinical knowledge that is not part of patient data. MESH HEADINGS: *Medical Records Systems, Computerized; *Medical Records, Problem-Oriented; Database Management Systems; Management Information Systems; Models, Theoretical; Human STANDARD NO.: 0195-4210 DATES: Entered 940421 RECORD NO.: 94028370 AUTHOR: van der Lei J; Duisterhout JS; Westerhof HP; van der Does E; Cromme PV; Boon WM; van Bemmel JH ADDRESS: Department of Medical Informatics, Faculty of Medicine and Health Sciences, Erasmus University, Rotterdam, The Netherlands. TITLE: The introduction of computer-based patient records in The Netherlands [see comments] SOURCE: Ann Intern Med (5A6), 1993 Nov 15; 119 (10): 1036-41 LANGUAGE: English COUNTRY PUB.: UNITED STATES ANNOUNCEMENT: 9401 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: Computer-based patient records, although an area of active research, are not in widespread use. In June 1992, 38% of Dutch general practitioners had introduced computer-based patient records. Of these, 70% had replaced the paper patient record with a computer-based record to retrieve and record clinical data during consultations. Possible reasons for the use of computer-based patient records include the nature of Dutch general practice and the early and active role of professional organizations in recognizing the potential of computer-stored patient records. Professional organizations issued guidelines for information systems in general practice, evaluated available systems, and provided postgraduate training that prepares physicians to use the systems. In addition, professional organizations successfully urged the government to reimburse general practitioners part of the expenses related to the introduction of computer-based patient records. Our experience indicates that physicians are willing and able to integrate information technology in their practices and that professional organizations can play an active role in the introduction of information technology. NOTES: Comment in: Ann Intern Med, 1993 Nov 15;119(10):1046-8 MESH HEADINGS: Family Practice--organization & administration (*OG); *Medical Records Systems, Computerized--economics (EC)/trends (TD)/utilization (UT); Practice Management, Medical--economics (EC)/trends (TD)/organization & administration (*OG); Database Management Systems; Financing, Government; Forecasting; National Health Programs; Netherlands; Societies, Medical; Human STANDARD NO.: 0003-4819 DATES: Entered 931119 RECORD NO.: 93393082 AUTHOR: Nagey DA; Blackman JA; Wright JN ADDRESS: Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore 21201. TITLE: The general medical record. Concepts and suggestions for implementation. SOURCE: Ann N Y Acad Sci (5NM), 1992 Dec 17; 670 109-15 LANGUAGE: English COUNTRY PUB.: UNITED STATES ANNOUNCEMENT: 9312 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: Our view of a general medical record consists of a combination of distinct departmental- and specialty-specific medical records and an organizing kernel that contains arguably critical information. Because this system allows each clinical entity to evolve its own system, clinical priorities do not have to be negotiated or compromised. Additionally, subsystem or departmental medical records can be easily revised without disturbing the general medical record because of the modular design. Although the system seems robust with respect to design considerations, only implementation can provide adequate tests. MESH HEADINGS: *Hospital Departments; Hospital Information Systems-- organization & administration (*OG); Medical Records Systems, Computerized--organization & administration (*OG); *Patient Care Team--organization & administration (OG); *Software Design; Bias (Epidemiology); Confidentiality; Health Facility Environment; Models, Organizational; Organizational Objectives; Professional Staff Committees; Human STANDARD NO.: 0077-8923 DATES: Entered 931021 RECORD NO.: 93309304 AUTHOR: Rector AL; Nowlan WA; Kay S; Goble CA; Howkins TJ ADDRESS: Department of Computer Science, University of Manchester, UK. TITLE: A framework for modelling the electronic medical record. SOURCE: Methods Inf Med (MVI), 1993 Apr; 32 (2): 109-19 LANGUAGE: English COUNTRY PUB.: GERMANY ANNOUNCEMENT: 9310 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: This paper presents a model for an electronic medical record which satisfies the requirements for a faithful and structured record of patient care set out in a previous paper in this series. The model underlies the PEN & PAD clinical workstation, and it provides for a permanent, completely attributable record of patient care and the process of medical decision making. The model separates the record into two levels: direct observations of the patient and meta-statements about the use of observations in decision making and the clinical dialogue. The model is presented in terms of "descriptions" formulated in the Structured Meta Knowledge (SMK) formalism, but many of its features are more general than the specific implementation. The use of electronic medical records based on the model for decision support and the analysis of aggregated data are discussed along with potential use of the model in distributed information systems. MESH HEADINGS: *Computer Simulation; *Medical Records Systems, Computerized; Data Display; Information Theory; Medical History Taking; Medical Record Linkage; Software; Human; Support, Non-U.S. Gov't STANDARD NO.: 0026-1270 DATES: Entered 930803 RECORD NO.: 93129999 AUTHOR: van Ginneken AM; van der Lei J; Moorman PW ADDRESS: Dept. of Medical Informatics, Erasmus University, Rotterdam, The Netherlands. TITLE: Towards unambiguous representation of patient data. SOURCE: Proc Annu Symp Comput Appl Med Care (BGL), 1992; 69-73 LANGUAGE: English COUNTRY PUB.: UNITED STATES ANNOUNCEMENT: 9304 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: In the early eighties, the goal set for the development of computer-based patient records was the creation of patient records that were analogous to the paper record. In the Netherlands, where the number of physicians using computer- based patient records is steadily increasing, this strategy has been proven successful. Although these "paper-like" computer-based patient records were suitable for patient care, they were much less suited for other purposes. Experiments showed that the use of data for other purposes than those for which they were recorded, can only be performed reliably when these data permit unambiguous interpretation. Due to a physician's limited time there is a constant tension between benefit and effort. Therefore, we should not expect the physician to provide the large amount of additional information, required for unambiguous interpretation of his record. Many of the inferences made by physicians are based on general knowledge and do not require specific, patient related information. We have focused our research on the potential of using knowledge about concepts in the patient record, to infer information, that is implicit in the patient data. The paper discusses considerations with respect to possible strategies to elicit a maximum of information with a minimum of effort from the physician. MESH HEADINGS: *Medical Records Systems, Computerized--standards (ST); Forms and Records Control; Quality of Health Care STANDARD NO.: 0195-4210 DATES: Entered 930212 RECORD NO.: 92017092 AUTHOR: Bishop CW ADDRESS: Department of Medicine, Erie County Medical Center, Buffalo, NY 14215. TITLE: A new format for the medical record. SOURCE: MD Comput (MDC), 1991 Jul-Aug; 8 (4): 208-15 LANGUAGE: English COUNTRY PUB.: UNITED STATES ANNOUNCEMENT: 9201 PUB. TYPE: JOURNAL ARTICLE ABSTRACT: Over the centuries, the medical record has become stereotyped. Reconsidering the purpose and organization of this document leads me to propose a four-part format consisting of administrative data, a patient synopsis, a chronological medical record, and a detailed medical record. The patient would be identified only in the administrative data section, leaving the rest of the record available for management, outcome, and cost studies, and protecting the patient's privacy. Adoption of this four-part format would make it easier to locate information in the medical record and would facilitate computerization. If the phraseology could be standardized, the new format would also allow easier data flow from one medical record to another and permit the construction of standardized disease profiles. Data on individual patients could then be compared with standardized profiles to identify deficiencies and redundancies in patient care. MESH HEADINGS: *Medical Records Systems, Computerized--standards (ST); Confidentiality; Database Management Systems; Nomenclature; Programming Languages STANDARD NO.: 0724-6811 DATES: Entered 911121