Yearbook of Medical Informatics, Table of Contents Yearb Med Inform 2006; 15(01): 29-39DOI: 10.1055/s-0038-1638464 Survey Georg Thieme Verlag KG Stuttgart Section 2: Patient Records: The Computerized Patient Record: Where Do We Stand? M. W. M. Jaspers 1 Department of Medical Informatics, Academic Medical Center, University of Amsterdam, The Netherlands , P. Knaup 2 Department of Medical Informatics, Institute for Medical Biometry and Informatics, University of Heidelberg, Germany , D. Schmidt 3 Department of Medical Informatics, University of Applied Sciences, Heilbronn, Germany › Author Affiliations Recommend Article Abstract Full Text PDF Download Keywords KeywordsMedical records systems, computerized - Computer security - Decision support systems, clinical - Evaluation studies - Health informatics, standardization References References 1 Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001 2 Barnett GO, Justice NS, Somand ME, Adams JB, Waxman DB, Beaman PD. et al. COSTARA computer-based medical information systems for ambulatory care. Proc IEEE 1979; 67: 1226-37. 3 Dayhoff RE, Sielge EL. Digital imaging within and among medical facilities. In: Kolodner RM. editor. Computerizing large integrated health networks. NewYork: Springer-Verlag; 1996: 473-90. 4 Gardner RM, Pryor TA, Warner HR. The HELP hospital information system: update 1998. Int J Med Inform 1999; 54 (03) 169-82. 5 Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ. et al. A cost-benefit analysis of electronic medical records in primary care. Am J Med 2003; 114: 397-403. 6 Hier DB, Rothschild A, LeMaistre A, Keeler J. Differing faculty and housestaff acceptance of an electronic health record. Int J Med Inform 2005; 74: 657-62. 7 Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004; 11: 300-9. 8 Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L. et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003; 10: 523-30. 9 Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health care records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc 2005; 12: 505-16. 10 Ammenwerth E, Gaus W, Lovis C, Pfeiffer KP, Tilg B, Wichmann HE. Cooperative care, collaborative research, ubiquitous information. Methods Inf Med 2005; 44: 481-2. 11 Lawrence DM. A comparison of organized and traditional health care. Methods Inf Med 2005; 44: 273-7. 12 Stefanelli M. Knowledge and process management in health care organizations. Methods Inf Med 2004; 43: 525-35. 13 Klar R. Selected impressions on the beginning of the electronic medical record and patient information. Methods Inf Med 2004; 43: 537-42. 14 Beale T. The health recordwhy is it so hard?. In: Haux R, Kulikowski C. IMIA Year book of Medical Informatics. 2005: 301-4. 15 Kluge EHW. Informed consent and the security of the electronic health record (EHR): some policy considerations. Int J Med Inform 2004; 73: 229-34. 16 Coiera E. e-Consent: The design and implementation of consumer consent mechanisms in an electronic environment. J Am Med Inform Assoc 2004; 11: 129-40. 17 Bernstein K, Bruun-Rasmussen M, Vingtoft S, Andersen SK, Nøhr C. Modelling and implementing electronic health records in Denmark. Int J Med Inform 2005; 74: 213-20. 18 Simons WW, Mandl KD, Kohane IS. The PING personally controlled electronic medical record system: Technical architecture. J Am Med Inform Assoc 2005; 12: 47-54. 19 Sax U, Kohane I, Mandl KD. Wireless technology infrastructures for authentication of patients: PKI that rings. J Am Med Inform Assoc 2005; 12: 263-8. 20 Jelekäinen P. GSM-PKI solution enabling secure mobile communications. Int J Med Inform 2004; 73: 317-20. 21 Pharow P, Blobel B. Electronic signatures for longlasting storage purposes in electronic archives. Int J Med Inform 2005; 74: 279-87. 22 Van den Brink JL, Moorman PW, De Boer MF, Pruyn JFA, Verwoerd CDA, Van Bemmel JH. Involving the patient: A prospective study on use, appreciation and effectiveness of an information system in head and neck cancer care. Int J Med Inform 2005; 74: 839-49. 23 Giorgino T, Azzini I, Rognonia C, Quaglini S, Stefanelli M, Gretter R. et al. Automated spoken dialogue system for hypertensive patient home management. Int J Med Inform 2005; 74: 159-67. 24 McAlearney AS, Schweikhart SB, Medow MA. Organizational and physician perspectives about facilitating handheld computer use in clinical practice: Results of a cross-site qualitative study. J Am Med Inform Assoc 2005; 12: 568-75. 25 Carroll AE, Tarczy-Hornoch P, O’Reilly E, Dimitri A. The effect of point-of-care personal digital assistant use on resident documentation discrepancies. Pediatrics 2004; 113: 450-4. 26 Reuss E, Menozzi M, Büchi M, Koller J, Krueger H. Information access at the point of care: what can we learn for designing a mobile CPR system?. Int J Med Inform 2004; 73: 363-9. 27 Chen ES, Mendonca EA, McKnight LK, Stetson PD, Lei J, Cimino JJ. PalmCIS: A wireless handheld application for satisfying clinician information needs. J Am Med Inform Assoc 2004; 11: 19-28. 28 Lu YC, Xiao Y, Sears A, Jacko JA. A review and a framework of handheld computer adoption in healthcare. Int J Med Inform 2005; 74: 409-22. 29 Mendonça EA, Chen ES, Stetson PD, McKnight LK, Lei J, Cimino JJ. Approach to mobile information and communication for health care. Int J Med Inform 2004; 73: 631-8. 30 Kushnirek AW, Triola MM, Borycki EM, Stein B, Kannry JL. Technology induced error and usability: The relationship between usability problems and prescription errors when using a handheld application. Int J Med Inform 2005; 74: 519-26. 31 Van der Meijden MJ, Tange HJ, Troost J, Hasman A. Determinants of success of inpatient clinical information systems: a literature review. J Am Med Inform Assoc 2003; 10: 235-243. 32 Nilsson G, Ahlfeldt H, Strender LE. Textual content, health problems and diagnostic codes in electronic patient records in general practice. Scan J Prim Care 2003; 21: 33-6. 33 Giere W. Electronic patient informationpioneers and muchmore. Methods Inf Med 2004; 43: 543-52. 34 Mikkelsen G, Aasly J. Consequences of impaired data quality on information retrieval in electronic patient records. Int J Med Inform 2005; 74: 387-94. 35 Owen RR, Thrush CR, Cannon D, Sloan KL, Curran G, Hudson T. et al. Use of electronic medical record data for quality improvement in schizophrenia treatment. J Am Med Inform Assoc 2004; 11: 351-7. 36 Rothschild AS, Dietrich L, Ball MJ, Wurtz H, Farish-Hunt H, Cortes-Comerer N. Leveraging systems thinking to design patient-centered clinical documentation systems. Int J Med Inform 2005; 74: 395-8. 37 Ammenwerth E, Eichstadter R, Haux R, Pohl U, Rebel S, Ziegler S. A randomized evaluation of a computer-based nursing documentation system. Methods Inf Med 2001; 40: 61-8. 38 Hippisley-Cox J, Pringle M, Cater R, Wynn A, Hammersley V, Coupland C. et al. The electronic patient record in primary care regression or progression: a cross sectional study. Br Med J 2003; 326: 1439-43. 39 Porcheret M, Hughes R, Evans D, Jordan K, Whitehurst T, Ogden H. et al. Data quality of general practice electronic health care records: the impact of a program of assessments, feedback and training. J Am Med Inform Assoc 2004; 11: 78-86. 40 Palermo TM, Valenzuela D, Stork PP. A randomized trial of electronic versus paper pain diaries in children: impact on compliance, accuracy and acceptability. Pain 2004; 107: 213-9. 41 Williams CA, Templin T, Mosley-Williams AD. Usability of a computer-assisted interview system for the unaided self-entry of patient data in an urban rheumatology clinic. J Am Med Inform Assoc 2004; 11: 249-59. 42 Porter SC, Kohane IS, Goldmann DA. Parents as partners in obtaining the medication history. J Am Med Inform Assoc 2005; 12: 299-305. 43 Shortliffe EH. The adolescence of AI in Medicine: will the field come of age in the ‘90s?. Artif Intell Med 1993; 05: 93-106. 44 Hasman A, Safran C, Takeda H. Quality of health care: informatics foundations. Methods Inf Med 2003; 42: 509-18. 45 Bakker A. Access to EHR and access control at a moment in the past: A discussion of the need and an exploration of the consequences. Int J Med Inform 2004; 73: 267-70. 46 Hazlehurst B, Frost HR, Sittig DF, Stevens VJ. MediClass: A system for detecting and classifying encounter-based clinical events in any electronic medical record. J Am Med Inform Assoc 2005; 12: 517-29. 47 Rosenbloom ST, Grande J, Geissbuhler A, Miller RA. Experience in implementing inpatient clinical note capture via a provider order entry system. J Am Med Inform Assoc 2004; 11: 310-5. 48 Hulse NC, Rocha RA, Del Fiol G, Bradshaw RL, Hanna TP, Roemer LK. KAT: a flexible XMLbased knowledge authoring environment. J Am Med Inform Assoc 2005; 12: 418-30. 49 Quaglini S, Grandi M, Baiardi P, Mazzoleni MC, Fassino C, Franchi G. et al. A computerized guideline for pressure ulcer prevention. Int J Med Inform 2000; 58-59: 207-17. 50 Junger A, Benson M, Quinzio L, Michel A, Sciuk G, Brammen D. et al. An Anesthsia Information Management System (AIMS) as a tool for controlling resource management of operation rooms. Methods Inf Med 2002; 41: 81-5. 51 Wu R, Peters W, Morgan MW. The next generation of clinical decision support: linking evidence to best practice. J HealthC Inf Manag 2002; 16 (04) 50-5. 52 Knaup P, Garde S, Merzweiler A, Graf N, Schilling F, Weber R. et al. Towards shared patient records: An architecture for using routine data for nationwide research. Int J Med Inform. In press; 2005 53 Los RK, Ginneken AM, Van der Lei J. Extracting data recorded with OpenSDE: Possibilities and limitations. Int J Med Inform 2005; 74: 473-80. 54 Los RK, Van Ginneken AM, Van der Lei J. OpenSDE: a strategy for expressive and flexible structured data entry. Int J Med Inform 2005; 74: 481-90. 55 Los RK, Roukema J, Van Ginneken AM, De Wilde M, Van der Lei J. Are structured data structured identically?. Methods Inf Med 2005; 44: 631-8. 56 Kulikowski CA. The micro-macro spectrum of medical informatics challenges: from molecular medicine to transforming health care in a globalizing society. Methods Inf Med 2002; 41: 20-4. 57 Colombet I, Aguirre-Junco AR, Zunino S, Jaulent MC, Leveneut L, Chatellier G. Electronic implementation of guidelines in the EsPeR system: A knowledge specification. Int J Med Inform 2005; 74: 597-604. 58 Ciccarese P, Caffi E, Quaglini S, Stefanelli M. Architectures and tools for innovative health information systems: the Guide project. Int J Med Inform 2005; 74: 553-62. 59 Rosille D, Laurent JF, Burgun A. Modelling a decision-support system for oncology using rulebased and case-based reasoning methodologies. Int J Med Inform 2005; 74: 299-306. 60 Ohno-Machado L, Gennari JH, Murphy SN, Jain NL, Tu SW, Oliver DE. et al. The GuideLine Interchange Format:A model for representing guidelines. J Am Med Inform Assoc 1998; 05: 357-72. 61 Peleg M, Boxwala AA, Tu S, Zeng Q, Ogunyemi O, Wang D. et al. The InterMed approach to sharable computer-interpretable guidelines: a review. J Am Med Inform Assoc 2004; 11: 1-10. 62 Aphinyanaphongs Y, Tsamardinos I, Statnikov A, Hardin D, Aliferis CF. Text categorization models for high-quality article retrieval in internal medicine. J Am Med Inform Assoc 2005; 12: 207-16. 63 Forster AJ, Andrade J, Van Walraven C. Validation of a discharge summary term search method to detect adverse events. J Am Med Inform Assoc 2005; 12: 200-6. 64 Melton GB, Hripcsak G. Automated detection of adverse events using natural language processing of discharge summaries. J Am Med Inform Assoc 2005; 12: 448-57. 65 Field TS, Gurwitz JH, Harrold LR, Rothschild JM, Debellis K, Seger AC. et al. Strategies for detecting adverse drug events among older persons in the ambulatory setting. J Am Med Inform Assoc 2004; 11: 492-8. 66 Samore MH, Evans RS, Lassen A, Gould P, Lloyd J, Gardner RM. et al. Surveillance of medical devicerelated hazards and adverse events in hospitalized patients. JAMA 2004; 291: 325-34. 67 Vandenberghe HE, Van Casteren V, Jonckheer P, Bastiaens H, Van der Heyden J, Lafontaine MF. et al. Collecting information on the quality of prescribing in primary care using semi-automatic data extraction from GPs’ electronic medical records. Int J Med Inform 2005; 74: 367-76. 68 Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE. et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293: 1197-203. 69 Bell DS, Marken RS, Meili RC, Wang CJ, Rosen M, Brook RH. Recommendations for comparing electronic prescribing systems: results of an expert consensus process. Health Aff (Millwood) 2004; Suppl Web Exclusives. W4-305-17. 70 Wang CJ, Marken RS, Meili RC, Straus JB, Landman AB, Bell DS. Functional characteristics of commercial ambulatory electronic prescribing systems: a field study. J Am Med Inform Assoc 2005; 12: 346-56. 71 Bell DS, Cretin S, Marken RS, Landman AB. A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc 2004; 11: 60-70. 72 Sellman JS, Decarolis D, Schullo-Feulner A, Nelson DB, Filice GA. Information resources used in antimicrobial prescribing. J Am Med Inform Assoc 2004; 11: 281-4. 73 Galanter WL, Polikaitis A, DiDomenico RJ. A trial of automated safety alerts for inpatient digoxin use with computerized physician order entry. J Am Med Inform Assoc 2004; 11: 270-7. 74 Galanter WL, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated medications using computerized physician order entry. J Am Med Inform Assoc 2005; 12: 269-74. 75 Rothschild AS, Lehmann HP. Information retrieval performance of probabilistically generated, proble mspecific computerized provider order entry picklists: a pilot study. J Am Med Inform Assoc 2005; 12: 322-30. 76 Bindels R, Hasman A, Van Wersch JWJ, Talmon J, Winkens RAG. Evaluation of an automated test ordering and feedback system for general practitioners in daily practice. Int J Med Inform 2004; 73: 705-12. 77 Hartge F, Wetter T, Haefeli WE. A similarity measure for case based reasoning modelling with temporal abstraction based on cross-correlation. Comp Meth Progr Biomed. In press 2006 78 Sittig DF, Krall M, Kaalaas-Sittig J, Ash JS. Emotional aspects of computer-based provider order entry: a qualitative study. J Am Med Inform Assoc 2005; 12: 561-7. 79 Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: are physicians ready?. J HealthC Manag 1999; 44: 440-54. 80 Short D, Frischer M, Bashford J. Barriers to the adoption of computerized decision support systems in general practice consultations: a qualitative study of GP’s perspectives. Int J Med Inform 2004; 73: 357-62. 81 Schectman JM, Schorling JB, Nadkarni MM, Voss JD. Determinants of physician use of an ambulatory prescription expert system. Int J Med Inform 2005; 74: 711-7. 82 Teich JM, Osheroff JA, Pifer EA, Sittig DF, Jenders RA. Clinical decision support in electronic prescribing: recommendations and an action plan: report of the joint clinical decision support workgroup. J Am Med Inform Assoc 2005; 12: 365-76. 83 O’Connell RT, Cho C, Shah N, Brown K, Shiffman RN. Take note(s): differential EHR satisfaction with two implementations under one roof. J Am Med Inform Assoc 2004; 11: 43-9. 84 Littlejohns P, Wyatt JC, Garvican L. Evaluating computerized health information systems : hard lessons still to be learnt. Br Med J 2003; 326 (7394): 860-3. 85 Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu N. et al. Installing and implementing a computer-based patient record system in SubSaharanAfrica:The Mosoriot medical record system. J Am Med Inform Assoc 2003; 10: 295-303. 86 Delpierre C, Cuzin L, Fillaux J, Alvarez M, Massip P, Lang T. A systematic review of computer-based patient record systems and quality of care: more clinical trials or a broader approach?. Int J Qual Health Care 2004; 16: 407-16. 87 Adams W, Mann A, Bauchner H. Use of an electronic medical record improves quality of urban pediatric care. Pediatrics 2003; 111: 626-32. 88 Rousseau N, McColl E, Newton J, Grimshaw J, Eccles M. Practice based, longitudinal, qualitative interview study of computerized evidence based guidelines in primary care. Br Med J 2003; 326: 314-22. 89 Lorenzi NM, Riley RT. Managing change: an overview. J Am Med Inform Assoc 2000; 07 (02) 116-24. 90 Goldstein MK, Coleman RW, Tu SW, Shankar RD, O’Connor MJ, Musen MA. et al. Translating research into practice: organizational issues in implementing automated decision support for hypertension in three medical centers. J Am Med Inform Assoc 2004; 11: 368-76. 91 Jaspers MWM, Steen T, Van den Bos C, Geenen M. The think-aloud method: a guide to user interface design. Int J Med Inform 2004; 73: 781-95. 92 Sciamanna CN, Novak SP, Marcus BH. Effects of using a computer in a doctor’s office on patient IMIA Yearbook of Medical Informatics 2006 attitudes towards using computerized prompts in routine care. Int J Med Inform 2005; 74: 357-65. 93 Hassol A, Walker JM, Kidder D, Rokita K, Young D, Pierdon S. et al. Patient experiences and attitudes about access to a patient electronic health record system and linked web messaging. J Am Med Inform Assoc 2004; 11: 505-13. 94 Hsu J, Huang J, Fung V, Robertson N, Jimison H, Frankel R. Health information technology and physician-patient interactions: impact of computers on communication during outpatient primary care visits. J Am Med Inform Assoc 2005; 12: 474-80. 95 Nøhr C, Andersen SK, Vingtoft S, Bernstein K, Bruun-Rasmussen M. Development, implementation and diffusion of EHR systems in Denmark. Int J Med Inform 2005; 74: 229-34. 96 Hübner U. Current and future use of ICT for patient care and management in German acute hospitals. A comparison of the nursing and the hospital managers’ perspectives. Methods Inf Med 2005; 44: 528-36. 97 Jaana M, Ward MM, Paré G, Wakefield DS. Clinical information technology in hospitals: A comparison between the state of Iowa and two provinces in Canada. Int J Med Inform 2005; 74: 719-31. 98 Siika AM, Rotich JK, Simiyu CJ, Kigotho EM, Smith FE, Sidle JE. et al. An electronic medical record system for ambulatory care of HIV-infected patients in Kenya. Int J Med Inform 2005; 74: 345-55. 99 DICOM. ftp://medical.nema.org/MEDICAL/ Dicom/Final/ Last access: January 2006 100 CEN TC/251 ENV13606. http:// www.centc251.org Last access: January 2006 101 Health Level 7. http://www.hl7.org Last access: January 2006 102 Open EHR. http://www.openEHR.org Last access: January 2006 103 Goossen WTF, Ozbolt JG, Coenen A, Park HA, Mead C, Ehnfors M, Marin HF. Development of a provisional domain model for the nursing process for use within the Health Level 7 reference information model. J Am Med Inform Assoc 2004; 11: 186-94. 104 Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV. et al. HL7 clinical document architecture, release 2. J Am Med Inform Assoc 2006; 13 (01) 30-9. 105 Müller ML, Ückert F, Bürkle T, Prokosch HU. Cross-institutional data exchange using the clinical document architecture (CDA). Int J Med Inform 2005; 74: 245-56. 106 Beuscart-Zéphir MC, Pelayo S, Anceaux F, Meaux JJ, Degroisse M, Degoulet P. Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. Int J Med Inform 2005; 74: 629-41. 107 Alberdi E, Taylor P, Lee R. Elicitation and Representation of Expert Knowledge for Computer Aided Diagnosis in Mammography. Methods Inf Med 2004; 43: 239-46. 108 Ammenwerth E, Mansmann U, Iller C, Eichstadter R. Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-years study. J Am Med Inform Assoc 2003; 10: 69-84. 109 Kuhn KA, Giuse DA. From hospital information systems to health information systemsproblems, challenges, perspectives. In: Haux R, Kulikowski C. IMIA Year book of Medical Informatics. 2001: 63-76. 110 Friedman C, Shagina L, Lussier Y, Hripcsak G. Automated encoding of clinical documents based on natural language processing. J Am Med Inform Assoc 2004; 11: 392-402. 111 Kaplan B, Shaw NT. Futue directions in evaluation research: people, organizational, and social issues. Methods Inf Med 2004; 43: 215-31. 112 Ammenwerth E, Shaw NT. Bad health informatics can killis evaluation the answer?. Methods Inf Med 2005; 44: 1-3. 113 Ammenwerth E, Keizer NF. An inventory of evaluation studies of information technology in health care. Methods Inf Med 2005; 44: 44-56. 114 Grémy F. Hardware, software, peopleware, subjectivity. Methods Inf Med 2005; 44: 352-8. 115 Kaushal R, Shojania K, Bates D. Effects of computerized physician order entry and clinical decision support systems on medication safety. Arch Intern Med 2003; 163: 1409-16. 116 Shabo A. A global socio-economic-medico-legal model for the sustainability of longitudinal electronic health records. Methods Inf Med. (accepted).
