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
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