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DOI: 10.1055/s-0038-1634388
The Index as a New Concept towards an Integrated Framework for the Electronic Patient Record
Publication History
Received
07 July 2001
Accepted
05 April 2002
Publication Date:
07 February 2018 (online)
Summary
Objective: To overcome some classical limitations of the POMR (Problem-Oriented Medical Record), including the management of divergent opinions between health professionals, in order to construct a common patient record across multiple disciplines in hospital settings and professional networks.
Methods: Using a complex clinical case, we improved a POMR model previously used by GPs in order to translate it into a hospital setting. The enhanced model has been assessed through use in various ongoing clinical cases and through extended discussion with professional end-users (physicians, nurses, general practitioners, and social workers).
Results: The Index concept (flexible structural link) is proposed as a major improvement in the construction of a POMR in a shared care environment.
Conclusions: The Index introduces interesting new perspectives. Following its implementation in the Belgian pilot site in the CORINES project, further studies remain to be carried out in order to develop a cost/benefit assessment.
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References
- 1 Epstein J. Historiography, diagnosis, and poetics. Lit Med 1992; 11 (Suppl. 01) 23-44.
- 2 Weed LL. Medical Records that Guide and Teach (concluded). N Eng J Med 1968; 278: 652-7. Reprint in: Van Bemmel JH, McGray AT, eds. IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer 1999; 212-7.
- 3 Weed LL. Medical Records that Guide and Teach. N Eng J Med 1968; 278: 652-7. Reprint in: Van Bemmel JH, McGray AT, eds. IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer 1999; 204-11.
- 4 CHIC Project (European Commission – AIM project A1026). Final Project Report. Cooper P. editor. Final Report. 1990
- 5 Deliège D, Taylor J, Mercier M. Vers l’information standardisée en soins ambulatoires. Louvain Med 1990; 109: 527-46.
- 6 De Clercq E, Christoph C, Deliège D. Dossier médical, réseaux et système intégré de soins. In: Albert A, Roger-France F, Degoulet P, Fieschi M. editors. Santé et réseaux informatiques. Springer-Verlag France; 1998: 56-64.
- 7 CEN/TC251/WG I – Project team 26. Health Informatics: Electronic Healthcare Communication – Part 1: Extended Architecture. ENV 13606-1. 29-6-1999. Brussels: European Committee for Standardization.;
- 8 van Ginneken AM, Stam H. Can one patient record accommodate the diversity of specialized care?. Proc Annu Symp Comput Appl Med Care. 1995: 406-10.
- 9 Hayes G. The Requirement on an Electronic Medical Record to Suit all Clinical Disciplines. In: van Bemmel JH, McCray A.T. editors. IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer; 1997: 75-82.
- 10 Heathfield HA, Hardiker N, Kirby J, Tallis R, Gonsalkarale M. The PEN & PAD medical record model: development of a nursing record for hospital-based care of the elderly. Methods Inf Med 1994; 33 (Suppl. 05) 464-72.
- 11 Nowlan WA, Rector AL, Kay S, Horan B, Wilson A. A patient care workstation based on user centred design and a formal theory of medical terminology: PEN&PAD and the SMK formalism. Proc Annu Symp Comput Appl Med Care. 1991: 855-7.
- 12 Berg M. Medical work and the computer-based patient record: a sociological perspective. Methods Inf Med 1998; 37 (Suppl. 03) 294-301.
- 13 Kay S, Purves IN. Medical records and other stories: a narratological framework. Methods Inf Med 1996; 35 (Suppl. 02) 72-87.
- 14 Rector AL, Nowlan WA, Kay S. Foundations for an electronic medical record. Methods Inf Med 1991; 30 (Suppl. 03) 179-86.
- 15 Salmon P, Rappaport A, Bainbridge M, Hayes G, Williams J. Taking the problem oriented medical record forward. Proc AMIA Annu Fall Symp. 1996: 463-7.
- 16 Tange HJ, Schouten HC, Kester ADM, Hasman A. The granularity of medical narratives and its effect on the speed and completeness of information retrieval. J Am Med Inform Ass 1998; Social-and-Behavioral-Sciences (Suppl. 06) 571-82.
- 17 van Ginneken AM, Stam H, Duisterhout JS. A powerful macro-model for the computer patient record. Proc Annu Symp Comput Appl Med Care. 1994: 496-500.
- 18 Rector AL, Nowlan WA, Kay S, Goble CA, Howkins TJ. A framework for modelling the electronic medical record. Methods Inf Med 1993; 32 (Suppl. 02) 109-19.
- 19 van Ginneken AM. The Structure of Data in Medical Records. In: van Bemmel JH, McCray AT. editors. IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer; 1995: 61-70.
- 20 Purves IN. A new health care record paradigm for family practice-goal orientation. Medinfo 1995; 8 Pt 1: 245-8.
- 21 Falcoff H. Le dossier orienté problème existe, je l’ai rencontré. In: Venot A, Falcoff H. editors. L’informatisation du Cabinet Médical du Futur. Springer-Verlag France; 1999: 149-57.
- 22 Moorman PW, van Ginneken AM, van der LJ, van Bemmel JH. A model for structured data entry based on explicit descriptional knowledge. Methods Inf Med 1994; 33 (Suppl. 05) 454-63.