Can one patient record accommodate the diversity of specialized care?
Despite a quarter century of developments, few specialists directly use a computerized patient record, that fully replaces the paper chart. Because of the diversity of domains in specialized care, medical decision-making and the continuity of care may suffer from scattering of patient data over various records. The challenge was to develop a computerized patient record, that would be versatile enough to tailor it to specific needs, while keeping it uniform enough to permit physicians to share data on the same patient. In our CPR, the key that reconciles versatility with uniformity lies in the design of the data model. The CPR consists of a mother record with specialized sub-records, that all share the same data model. A physician can enlarge his scope for decision-making by consulting other specialized records on the same patient or by viewing the combined information of all sub-records without the need to convert data or to familiarize himself with different interfaces.
van Ginneken
A M
AM
Department of Medical Informatics, Erasmus University, Rotterdam, The Netherlands.
Stam
H
H
D006801:Humans; D016247:Information Storage and Retrieval / Q000592:standards*; D008498:Medical Record Linkage / Q000379:methods*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D008511:Medicine; D013038:Specialization; D018511:Systems Integration; D014584:User-Computer Interface