Naming Notes: Transitions from Free Text to Structured Entry

J. Gregory; J. E. Mattison; C. Linde

doi:10.1055/s-0038-1634580

Methods of Information in Medicine, Table of Contents

Methods Inf Med 1995; 34(01/02): 57-67
DOI: 10.1055/s-0038-1634580

Original article

Schattauer GmbH

Naming Notes: Transitions from Free Text to Structured Entry

J. Gregory

¹Department of Communication, University of California at San Diego, La Jolla CA

⁴Institute for Research on Learning (IRL), Palo Alto CA, USA

,

J. E. Mattison

²Clinical Information Systems, Kaiser Permanente Medical Group, Southern California Region, Pasadena CA

³University of California at San Diego, School of Medicine, La Jolla CA

,

C. Linde

⁴Institute for Research on Learning (IRL), Palo Alto CA, USA

› Author Affiliations

Abstract

Abstract:

To practice medicine in the near future, health care providers in the USA need an information infrastructure they do not yet have. We offer a contribution from social science research to discussions of current medical records practices and how health care activity systems may be transformed by the advent of electronic health records. The goal of the paper is to set forth a framework that connects over-arching questions concerning medical informatics systems development with the practical, cultural and conceptual issues involved in transitions from handwritten and other free text documentation to structured entry of medical records to build patient profiles. The research is broadly framed by an interest in how reciprocal modifications of the design and use of an electronic health record are negotiated in an iterative prototyping project. It is conducted as part of a complex multi-disciplinary research and development effort to create an electronic health record prototype for use in the integrated health care delivery environment of the Southern California Kaiser Permanente Medical Care Program.

Keywords:

Electronic Health Records - Electronic Medical Records - Computer-based Patient Records - Medical Vocabulary - Medical Practice - Diagnostic Codes

Full Text

References

References
1 Bodker S. Through the Interface: A Human Activity Approach to User Interface Design . Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers; 1991
2 Ehn P. Work-Oriented Design of Computer Artifacts. Stockholm: Almquist & Wiksell; 1988
3 Greenbaum J, Kyng M. eds. Design at Work: Cooperative Design of Computer Systems. Hillsdale, NJ: Lawrence Erlbaum Associates; 1991
4 Suchman LA. Plans and Situated Actions, The Problem of Human Machine Communication. Cambridge: Cambridge University Press; 1987
5 Suchman LA, Jordan B. Computerization and women’s knowledge. in Tijdens K, Jennings M, Wagner I, Weggelaar M. eds. Women, Work and Computerization: Forming New Alliances, IFIP. Amsterdam: North-Holland Publ; 1989: 153-60.
6 Timpka T. Design of Computer-Based Decision Support for General Practitioners. Linköping University Medical Dissertations No. 298 Depts. of Medical Informatics, Social and Preventive Medicine, and Computer and Information Science; 1989
7 Weickert K. Expert Systems in Organizations: Projecting Use from the Context of Design. dissertation Dept. of Information and Computer Science, UC-Irvine; 1995
8 Harber P. Work coding: beyond SIC and SOC, BOC and DOT. J of Occ Med 1991; 33: 1274-80.
9 Argyris C, Putnam R, Smith DM. Action Science. San Francisco: Jossey-Bass; 1985
10 Argyris C, Schon DA. Organizational Learning: a Theory of Action Perspective. Reading, MA: Addison-Wesley Pub. Co.; 1978
11 Glasser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Hawthorne, NY: Aldine Publishing Company; 1980
12 Schön DA. Educating the Reflective Practitioner. San Francisco: Jossey-Bass Publishers; 1987
13 Chaiklin S, Lave J. eds. Understanding Practice, Perspectives on Activity and Context. Cambridge: Cambridge University Press; 1993
14 Engeström Y. Developmental work research: reconstructing expertise through expansive learning. in Nurrninen MI, Weir GRS. eds. Human Jobs and Computer Interfaces. Amsterdam: Elsevier Science Publ; 1991
15 Engeström Y. When is a tool?. In: Learning, Working and Imagining, Twelve Studies in Activity Theory. Helsinki, Finland: Orienta-Konsultit; 1990
16 Engeström Y, Brown K, Christopher LC, Gregory J. Coordination, cooperation and communication in the courts: expansive transition in legal work. Quarterly Newsletter of the LCHC 13: 88-97.
17 Engeström Y, Engeström R, Saarelma O. Computerized medical records, production pressure and compartmentalization in the work activity of health care physicians. Proceedings of the Conference on Computer-Supported Cooperative Work. 1988. Portland, OR: AMC; 65-84.
18 Johnson BM. Communication: the Process of Organizing. Boston MA: American Press; 1981
19 Winograd T, Flores F. Understanding Computers and Cognition: A New Foundation for Design. Norwood NJ: Ablex Publishing Corp; 1986
20 Storper M, Walker R. The Capitalist Imperative: Territory, Technology and Industrial Growth. New York: Basil Blackwell; 1989
21 Hutchins E. Cognition in the Wild. Cambridge MA: MIT Press; 1994
22 Latour B. Science in Action: How to Follow Scientists and Engineers Through Society. Cambridge, MA: Harvard University Press; 1987
23 Saarelma O. Descriptions of subjective networks as a mediator of developmental dialogue, The Working Health Center Project: Helsinki, Finland, 1992. presented at the International Conference on Discourse and the Professions, 26-29 Aug. 1992. Uppsala, Sweden.:
24 Timpka T, Arborelius E. A method for study of dilemmas during health care consultations. Medical Inform 1991; 16: 55-64.
25 Timpka T, Arborelius E. The primary-care nurse’s dilemmas: a study of knowledge use and need during telephone consultations. J of Adv Nursing 1990; 15: 1457-65.
26 Wartofsky MW. Perception, representation, and the forms of action: towards an historical epistemology. in Models, Representation and the Scientific Understanding. Boston, MA: D. Reidel Publishing Co; 1979
27 Kindermann AH. Anthropology and participatory work design. unpublished paper presented at the American Anthropological Association San Francisco: 1992
28 Schwartzman HB. Ethnography in Organizations. Qualitative Research Methods, Vol. 27. Newbury Park, CA: Sage Publ; 1993
29 Gilbert MJ, Tashima N, Fishman CC. Ethics and practicing anthropologists’ dialogue with the larger world: considerations in the formulation of ethical guidelines for practicing anthropologists. In: Fluer-Lobban C. ed. Ethics and the Profession of Anthropology: Dialogue for a New Era. Philadelphia PA: Pennsylvania University Press; 1991: 198-210.
30 Institute of Medicine. Dick RS, Steen EB. eds. The Computer-Based Patient Record, An Essential Technology for Health Care. Washington, DC: National Academy Press; 1991
31 Latour B. The Pasteurization of France. Cambridge MA: Harvard University Press; 1988
32 Hogan RW, Mattison J. Toward the electronic medical record: in pursuit of an electronic Holy Grail in a cost-conscious era (editorial). HMO Practice 1993; 7: 54-5.
33 Campbell KE, Wieckert K, Fagan LM, Musen MA. A computer-based tool for generation of progress notes. In: Proceedings of the Seventeenth Annual SCAMC. New York: McGraw Hill; 1993: 284-8.
34 Harber P, McCoy JM, Shimozaki S, Coffman P, Bailey K. The structure of expert diagnostic knowledge in occupational medicine. Amer J of Int Med 1990; 19: 109-20.
35 Ohno-Machado L, Parra E, Henry SB, Tu SW, Musen MA. AIDS: a decision-support tool for decreasing uncertainty regarding patient eligibility for HIV treatment protocols. In: Proceedings of the Seventeenth SCAMC. New York: McGraw Hill; 193: 429-33.
36 Safran C, Rind DM, Davis RM. An electronic medical record that helps care for patients with HIV infection. In: Proceedings of the Seventeenth SCAMC. New York: McGraw Hill; 1993: 224-8.
37 Ball MJ, Hannah KJ, Jelger UG, Peterson H. eds. Nursing Informatics: Where Caring and Technology Meet. New York: Springer-Verlag; 1988
38 Henry SB, LeBreck DB, Holzemer WL. The effect of verbalization of cognitive processes on clinical decision making. Research on Nursing & Health 1989; 12: 187-93.
39 Nyce JM, Timpka T. Work, knowledge and argument in specialist consultations: incorporating tacit knowledge into systems design and development. Med & Bio Eng & Camp 1993; 31: HTA16-HTA19.
40 Timpka T, Bjurulf P. The semantics of diagnosis and management of genitourinary infections – a cross-specialty study. Family Practice 1989; 6: 279-85.
41 Timpka T, Ekstrom M, Bjurulf P. Information needs and information seeking behavior in primary health care. Scand J of Primary Health Care 1989; 7: 105-9.
42 Wirtschafter D, Mesel E. A strategy for redesigning the medical record for quality assurance. Medical Care 1976; 14: 68-76.
43 Campbell KE. Distributed Development of a Logic-Based Controlled Medical Terminology. unpublished dissertation proposal Palo Alto, CA: Program in Medical Information Sciences, Stanford University; 1994
44 Campbell KE, Das AK, Musen MA. A logical foundation for representation of clinical data. Stanford CA: 1994
45 Henry SB, Holzemer WL, Reilly CA, Campbell KE. Terms used by nurses to describe patient problems: can SNOMED III represent nursing concepts in the patient record?. J Amer Med Info Assoc 1994; 1: 61-74.
46 Henry SB, Campbell KE, Holzemer WL. Representation of nursing terms for the description of patient problems using SNOMED III. In: Proceedings of the Seventeenth SCAMC. New York: McGraw Hill; 1993: 700-4.
47 Lindberg DAB, Humphreys BL, McCray AT. The Unified Medical Language System. In: Van Bemmel JH, McCray AT. eds. Yearbook of Medical Informatics. Stuttgart: Schattauer Verlag; 1993: 281-91.
48 Musen MA. Dimensions of knowledge sharing and reuse. Camp Biomed Res 1992; 25: 435-67.
49 Arborelius E, Bremberg S, Timpka T. What is going on when the general practitioner doesn’t grasp the situation?. Family Practice 1991; March 8 (01) 3-9.
50 Harber P, McCoy JM. Predicate calculus, artificial intelligence, and workers’ compensation. J of Occ Med 1989; 31: 484-9.
51 Jordan B. Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States. Montreal, Quebec and St. Albans, VT: Eden Press Women’s Publ; 1978
52 ICD-9-CM, International Classification of Diseases, 9th Revision, Clinical Modification, 4th Edition, 1993. Hospital Edition Vols 1, 2 & 3. Los Angeles, CA: Practice Management Information Corporation; 1993
53 Bowker G, Star SL. Knowledge and infrastructure in international information management problems of classification and coding. In: Bud-Frierman L. ed. Information Acumen: the Understanding and Use of Knowledge in Modern Business. London: Routledge; 1994
54 Dewey JB, Manning P, Brandt S. Acceptance of direct physician access to a computer-based patient record in managed care settings. In: Proceedings of the Seventeenth SCAMC. New York: McGraw Hill; 1994: 79-83.
55 Pine II BJ, Victor B, Boynton AC. Making mass customization work. Harvard Business Review Sept-Oct 1993; 108-19.
56 Hendricks R. A Model for National Health Care, The History of Kaiser Permanente. New Brunswick NJ: Rutgers University Press; 1993
57 Geist P, Hardesty M. Negotiating the Crisis: DRGs and the Transition of Hospitals. Hillsdale, NJ: Lawrence Erlbaum; 1992
58 Billig M, Condor S, Edwards D, Gane M, Middleton D, Radley A. Ideological Dilemmas, A Social Psychology of Everyday Thinking. Newbury Park, CA: Sage Publications; 1988