PubMed · 8261253
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S Pocock. 1993. Meta-analysis.. https://doi.org/10.1177/096228029300200201
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The development and dissemination of Electronic Medical Records (EMR) is impeded because of several reasons. One of the reasons is considered the 'unruliness' of narrative data. In this article it is illustrated how the medical record can be structured to make it accessible from different perspectives, without the need to change the free text format of the narratives. The organising principles behind three existing medical record structures are analysed: the source-oriented, problem-oriented and time-oriented medical record. These principles are combined in a model of the medical record with four different views on medical data: a typological view, a time view, a problem view, and a process view. A data model is presented in which each of these views can be defined. In the discussion some examples are given of EMRs in which some of these views have been applied on coded data.
Despite a number of well recognized shortcomings of paper medical records, the use of a Computer Patient Record (CPR) is not widespread among specialists. The complexity of specialized care combined with the diversity of their domains of expertise, make it a challenge to design a CPR that satisfies the needs of a specialist. Ideally, CPRs are tailored to the specific tasks of each user, and yet general enough to permit exchange and sharing of information. The basic philosophy behind our CPR is a 'mother' record, which is extended with specialized sub-records. Two different types of subrecords are discussed: one to accommodate standardized data entry in the context of a specialty or research protocol, and another for structured recording of accidental findings outside one's own domain of expertise. The CPR supports the entry of free text and does not impose structured data entry on the physician, but stimulates him to do so by confronting him with the benefits of a structured CPR.