Selected impressions on the beginning of the electronic medical record and patient information.
OBJECTIVE
To present an overview of early European and American work on Electronic Medical Records and patient information.


METHODS
The invited lectures of "pioneers of electronic patient information" given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed.


RESULTS
The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first computerized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency.


CONCLUSIONS
Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.
Klar
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Department of Medical Informatics, University Hospital Freiburg, Freiburg, Germany. klar@mi.ukl.uni-freiburg.de
D004059:Diffusion of Innovation; D005858:Germany; D016347:Medical Records Systems, Computerized / Q000145:classification / Q000592:standards