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Proceedings of the Annual Symposium on Computer Application in Medical Care logoLink to Proceedings of the Annual Symposium on Computer Application in Medical Care
. 1992:69–73.

Towards unambiguous representation of patient data.

A M van Ginneken 1, J van der Lei 1, P W Moorman 1
PMCID: PMC2248077  PMID: 1482959

Abstract

In the early eighties, the goal set for the development of computer-based patient records was the creation of patient records that were analogous to the paper record. In the Netherlands, where the number of physicians using computer-based patient records is steadily increasing, this strategy has been proven successful. Although these "paper-like" computer-based patient records were suitable for patient care, they were much less suited for other purposes. Experiments showed that the use of data for other purposes than those for which they were recorded, can only be performed reliably when these data permit unambiguous interpretation. Due to a physician's limited time there is a constant tension between benefit and effort. Therefore, we should not expect the physician to provide the large amount of additional information, required for unambiguous interpretation of his record. Many of the inferences made by physicians are based on general knowledge and do not require specific, patient related information. We have focused our research on the potential of using knowledge about concepts in the patient record, to infer information, that is implicit in the patient data. The paper discusses considerations with respect to possible strategies to elicit a maximum of information with a minimum of effort from the physician.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Branger P. J., Duisterhout J. S. Electronic Data Interchange in medical care: an evaluation study. Proc Annu Symp Comput Appl Med Care. 1991:58–62. [PMC free article] [PubMed] [Google Scholar]
  2. Kent D. L., Shortliffe E. H., Carlson R. W., Bischoff M. B., Jacobs C. D. Improvements in data collection through physician use of a computer-based chemotherapy treatment consultant. J Clin Oncol. 1985 Oct;3(10):1409–1417. doi: 10.1200/JCO.1985.3.10.1409. [DOI] [PubMed] [Google Scholar]
  3. Koran L. M. The reliability of clinical methods, data and judgments (second of two parts). N Engl J Med. 1975 Oct 2;293(14):695–701. doi: 10.1056/NEJM197510022931405. [DOI] [PubMed] [Google Scholar]
  4. Lomas J., Anderson G. M., Domnick-Pierre K., Vayda E., Enkin M. W., Hannah W. J. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989 Nov 9;321(19):1306–1311. doi: 10.1056/NEJM198911093211906. [DOI] [PubMed] [Google Scholar]
  5. Lomas J. Words without action? The production, dissemination, and impact of consensus recommendations. Annu Rev Public Health. 1991;12:41–65. doi: 10.1146/annurev.pu.12.050191.000353. [DOI] [PubMed] [Google Scholar]
  6. Quaak M. J., Westerman R. F., van Bemmel J. H. Comparisons between written and computerised patient histories. Br Med J (Clin Res Ed) 1987 Jul 18;295(6591):184–190. doi: 10.1136/bmj.295.6591.184. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Reiser S. J. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med. 1991 Jun 1;114(11):980–985. doi: 10.7326/0003-4819-114-11-980. [DOI] [PubMed] [Google Scholar]
  8. Shortliffe E. H., Tang P. C., Detmer D. E. Patient records and computers. Ann Intern Med. 1991 Dec 15;115(12):979–981. doi: 10.7326/0003-4819-115-12-979. [DOI] [PubMed] [Google Scholar]
  9. Whiting-O'Keefe Q. E., Simborg D. W., Epstein W. V., Warger A. A computerized summary medical record system can provide more information than the standard medical record. JAMA. 1985 Sep 6;254(9):1185–1192. [PubMed] [Google Scholar]
  10. van der Lei J., Musen M. A. A model for critiquing based on automated medical records. Comput Biomed Res. 1991 Aug;24(4):344–378. doi: 10.1016/0010-4809(91)90034-t. [DOI] [PubMed] [Google Scholar]
  11. van der Lei J., Musen M. A., van der Does E., Man in 't Veld A. J., van Bemmel J. H. Comparison of computer-aided and human review of general practitioners' management of hypertension. Lancet. 1991 Dec 14;338(8781):1504–1508. doi: 10.1016/0140-6736(91)92311-o. [DOI] [PubMed] [Google Scholar]
  12. van der Lei J. Use and abuse of computer-stored medical records. Methods Inf Med. 1991 Apr;30(2):79–80. [PubMed] [Google Scholar]

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