PubMed Health⌕ Search

SEARCH · PubMed Health

Results for “Medical Records Systems, Computerized”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 145 records · Page 8Linked to original sources
PubMed1993

Feasibility of ensuring confidentiality and security of computer-based patient records. Council on Scientific Affairs, American Medical Association.

Legal and ethical precepts that apply to paper-based medical records, including requirements that patient records be kept confidential, accurate and legible, secure, and free from unauthorized access, should also apply to computer-based patient records. Sources of these precepts include federal regulations, state medical practice acts, licensing statutes and the regulations that implement them, accreditation standards, and professional codes of ethics. While the legal and ethical principles may not change, the risks to confidentiality and security of patient records appear to differ between paper- and computer-based records. Breaches of system security, the potential for faulty performance that may result in inaccessibility or loss of records, the increased technical ability to collect, store, and retrieve large quantities of data, and the ability to access records from multiple and (sometimes) remote locations are among the risk factors unique to computer-based record systems. Managing these risks will require a combination of reliable technological measures, appropriate institutional policies and governmental regulations, and adequate penalties to serve as a dependable deterrent against the infringement of these precepts.

Computer Security↗
PubMedDate not supplied

Computerized record system for electro-medical equipment management.

Commercial data-base software with a business-type microcomputer (Commodore 8096) has been used for filing electro-medical equipment inventory information. The operational experience of this system as an aid to comprehensive equipment management is described.

Computers↗
PubMed1994

Coping with changing controlled vocabularies.

For the foreseeable future, controlled medical vocabularies will be in a constant state of development, expansion and refinement. Changes in controlled vocabularies must be reconciled with historical patient information which is coded using those vocabularies and stored in clinical databases. This paper explores the kinds of changes that can occur in controlled vocabularies, including adding terms (simple additions, refinements, redundancy and disambiguation), deleting terms, changing terms (major and minor name changes), and other special situations (obsolescence, discovering redundancy, and precoordination). Examples are drawn from actual changes appearing in the 1993 update to the International Classification of Diseases (ICD9-CM). The methods being used at Columbia-Presbyterian Medical Center to reconcile its Medical Entities Dictionary and its clinical database are discussed.

Medical Records Systems, Computerized↗
PubMed1993

Toward an interim standard for patient-centered knowledge-access.

Most care-giver "knowledge" needs arise at the point of care and are "patient-centered." Many of these knowledge needs can be met using existing on-line knowledge sources, but the process is too time-consuming, currently, for even the computer-proficient. We are developing a set of public domain standards aimed at bringing potentially relevant knowledge to the point of care in a straight-forward and timely fashion. The standards will a) make use of selected items from a Computer-based Patient Record (CPR), e.g., a diagnosis and measure of severity, b) anticipate certain care-giver knowledge needs, e.g., "therapy," "protocols," "complications," and c) try to satisfy those needs from available knowledge sources, e.g., knowledge-bases, citation databases, practice guidelines, and on-line textbooks. The standards will use templates, i.e., fill-in-the-blank structures, to anticipate knowledge needs and UMLS Metathesaurus enhancements to represent the content of knowledge sources. Together, the standards will form the specification for a "Knowledge-Server" (KS) designed to be accessed from any CPR system. Plans are in place to test an interim version of this specification in the context of medical oncology. We are accumulating anecdotal evidence that a KS operating in conjunction with a CPR is much more compelling to users than either a CPR or a KS operating alone.

Artificial Intelligence↗
PubMed1991

From patient reports to bibliographic retrieval: a Meta-1 front-end.

A software front-end has been programmed to help construct Medline query expressions from selected text in clinical records. The user "clicks" to choose pertinent words or phrases from the text with a pointing device and the words are translated into Medical Subject Headings (MeSH). The National Library of Medicine's Unified Medical Language System Meta-1 Thesaurus is used to look up the words selected by the user. The software traces through chains of synonyms to assemble a small set of MeSH indexing terms. The user then makes the final selection from among the MeSH terms and combines chosen terms using logical connectives to form a Medline query which is passed on to Grateful Med. This approach provides the clinical user with a natural starting point, the text of a patient report with no need to know the MeSH terminology. The software handles the translation that otherwise would necessitate looking up terms in MeSH guidebooks, as well as handling the added drudgery of checking out different synonyms. Preliminary evaluation of this approach with clinical trainees indicated that they find the front-end a straightforward way to search for literature relevant to a clinical case. Having a tool for immediate translation from clinical terminology to indexing terminology seems to be an important factor. Apparently minor issues in interface design, such as keeping the clinical report displayed simultaneously along with the search under construction, and keeping both visible during the search itself seem to help orient the user.

Grateful Med↗
PubMed1991

[The microcomputer in the office of the community pediatrician].

The material submitted is a draft model system for the use of a microcomputer in the daily working activity of the community paediatrician. His work comprises preventive and therapeutic care of children and he has specific tasks and specific orientation on different age groups and the ensuing administrative work. The introduction of the information system in the surgery gives an idea of its asset for the user.

Medical Records Systems, Computerized↗