RSS-Feed abonnieren
DOI: 10.1055/s-0038-1633913
Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information
Publikationsverlauf
Publikationsdatum:
05. Februar 2018 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00035037/200405/lookinside/thumbnails/10-1055-s-0038-1633913-1.jpg)
Summary
Objectives: To present an overview of early European and American work on Electronic Medical Records and patient information.
Method: 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 com-puterized 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.
-
References
- 1 Giere W. Electronic Patient Information – Pioneers and MuchMore. A Vision, Lessons Learned and Challenges. Methods Inf Med 2004; 43 (05) ••• xxx
- 2 Giere W. BAIK Befunddokumentation und Arztbriefschreibung im Krankenhaus. Taunusstein: Media Verlag; 1986
- 3 Proppe A. Die ärztliche Aufgabe und die Dokumentation. Meth Inform Med 1964; 3: 10-7.
- 4 Waxman BD. Biomedical computing 1965. Ann NY Acad Sci. 1964: 723-30.
- 5 Berkson J. A system of codification of medical diagnoses for application to punch cards. Amer J Publ Hlth 1936; 26: 606-12.
- 6 Mikat B. Archivierung und Dokumentation der Krankenblätter im Zentralarchiv für Wehrmedizin. Wehrmed Mitt 1960; 6: 81-5.
- 7 Arbeitsausschuss Medizin in der DGD: Ein dokumentationsgerechter Krankenblattkopf für stationäre Patienten aller klinischen Fächer (sog. Allgemeiner Krankenblattkopf). Med Dok 1961; 5: 57-70.
- 8 Barnett GO. The application of computer-based medical-record systems in ambulatory practice. NEJM 1984; 310: 1643-50.
- 9 Barnett GO, Justice NS, Somand ME. et al. COSTAR – A computer-based medical information system for ambulatory care. Proc IEEE 1979; 67: 1226-37.
- 10 Grossman JH, Barnett GO, Koepsell TD. et al. An automated medical record system. JAMA 1973; 224: 1616-21.
- 11 Dayhoff RE, Sielge EL. Digital Imaging Within and Among Medical Facilities. In Kolodner RM. (ed) Computerizing Large Integrated Health Networks. Springer-Verlag, New York: 1996: 473-90.
- 12 Brown SH, Lincoln M, Hardenbrook S, Petukhova ON, Rosenbloom ST, Carpenter P, Elkin P. Derivation and Evaluation of a Document Naming Nomenclature. J Am Med Inform Assoc 2001; 8 (04) 379-90.
- 13 Kaplan B, Lundsgaarde HP. Toward an Evaluation of a Clinical Imaging System: Identifying Benefits. Methods Inf Med 1996; 35: 221-9.
- 14 Giere W. BAIK Befunddokumentation und Arztbriefschreibung im Krankenhaus. Taunusstein: Media Verlag; 1986
- 15 Giere W. Treatment, Teaching and Research – structural requirements for medical records, the information model of BAIK. In: 8th Joint Conference on Medical Informatics (JCMI). 1988. Tokyo, Japan:
- 16 Fleck E. Need for Improved Quality in Health Care and Medical Diagnosis. In Fleck E. editor Open Systems in Med. Amsterdam: IOS-Press; 1995: 3-5.
- 17 Warner HR, Olmstead CM, Rutherford BD. HELP – A Program for Medical Decision-Making. Computers and Biomedical Research 1972; 5: 65-74.
- 18 Warner HR. Computer-Assisted Medical Decisionmaking. New York: Academic Press; 1979
- 19 Gardner RM, Pryor TA, Warner HR. The HELP hospital information system: update 1998. Int Med Inform 1999; 54: 169-82.
- 20 Satomura Y, Yamazaki S, Sasaki T. A terminology of diagnosis with ICD10 classification and an automatic coding system. 15th JCMI. 1995: 957-60.
- 21 Zansta PE, Rector AL, Ceusters W, de Vries Robbe PF. Coding systems and classifications in healthcare: the link to the record. Int Med Inform 1998; 48 (1–3) 103-9.
- 22 Liu Y, Satomura Y. Building a controlled health vocabulary in Japanese. Meth Inform Med 2001; 40 (04) 307-14.
- 23 Chute CG. Clinical classification and terminology: some history and current observations. American Med Inform Assoc 2000; 7 (03) 298-303.
- 24 Schopen M. ICD-10 Thesaurus – An Alternative to the ICD-10 Alphabetical Index? Proceedings of the International Collaborative Effort on Automating Mortality Statistics. Washington, April 7–10. 2003. Washington: National Centre for Health Statistics, under preparation;
- 25 www.bvmi.de/historie_mi.htm
- 26 Blum BI, Duncon K. A History of Medical Informatics. AMIA. 1990
- 27 Collen MF. A History of Medical Informatics in the United States 1950 to 1990. ACM Press History Series. 1995
- 28 Ball M. Hospital Information Systems: Perspectives on Problems and Prospects. Lecture notes of the IMIA WG 10 meeting. 2002
- 29 Patel V, Rogers R, Haux R. Medinfo 2001. Proceed 10th World Congress on Medical Informatics, Vol 84 Studies in Health Technology and Informatics. IOS Press Amsterdam; 2001
- 30 Ehlers CT, Klar R. The Information System of the Göttingen University Hospital. In O’Moore R. et al. (eds) Medical Informatics Europe 82. Springer: Berlin; 1982: 21-7.
- 31 Klar R, Schulz S. Gedanken zur Lage und Zukunft der Medizinischen Informatik in Deutschland. mdi Forum der Medizinischen Dokumentation und Medizin Informatik. 2004. Sept 27-35.
- 32 Köhler CO. Integriertes Krankenhaus-Informationssystem. Verlag Anton Hain: Meisenheim; 1973
- 33 Dudeck J. Computeranalyse des Elektrodiagramms. Klinische Wochenschrift 1971; 49 (13) 717-29. and 49 (14), 729-38
- 34 Bang M, Timpka T. Cognitive tools in medical teamwork: the spatial arrangement of patient records. Methods Inf Med 2003; 42 (04) 331-6.
- 35 Bisbal J, Grimson J, Grimson W, Berry D, Hederman L. From passive to active electronic healthcare records. Methods Inf Med 2003; 42 (05) 535-43.
- 36 Clayton PD, Narus SP, Huff SM. et al. Building a comprehensive clinical information system from components. The approach at Intermountain Health Care. Methods Inf Med 2003; 42 (01) 1-7.
- 37 De Clercq E. The index as a new concept towards an integrated framework for the electronic patient record. Methods Inf Med 2002; 41 (04) 313-20.
- 38 Gell G, Schmucker P, Pedevilla M. et al. IS-H and IS-H* MED. Methods Inf Med 2003; 42 (01) 16-24.
- 39 Giuse DA. Provider order entry with integrated decision support: from academia to industry. Methods Inf Med 2003; 42 (01) 45-50.
- 40 Haux R, Seggewies C, Baldauf-Sobez W. et al. Soarian- workflow management applied for health care. Methods Inf Med 2003; 42 (01) 25-36.
- 41 Jensen CB. The ’Seamless Web’: the development of the electronic patient record in Aarhus region, Denmark. Methods Inf Med 2003; 42 (04) 405-9.
- 42 Kuhn KA, Lenz R, Elstner T, Siegele H, Moll R. Experiences with a generator tool for building clinical application modules. Methods Inf Med 2003; 42 (01) 37-44.
- 43 Lechleitner G, Pfeiffer KP, Wilhelmy I, Ball M. Cerner Millennium: the Innsbruck experience. Methods Inf Med 2003; 42 (01) 8-15.
- 44 Tange HJ. Consultation of medical narratives in the electronic medical record. Methods Inf Med 1999; 38 4-5 289-93.
- 45 Vlug AE, van der Lei J, Mosseveld BM, van Wijk MA. et al. Postmarketing surveillance based on electronic patient records: the IPCI project. Methods Inf Med 1999; 38 4-5 339-44.
- 46 Ellingsen G, Monteiro E. Big is beautiful: electronic patient records in large Norwegian hospitals 1980s-2001. Methods Inf Med 2003; 42 (04) 366-70.
- 47 Faber MG. Design and introduction of an electronic patient record: how to involve users?. Methods Inf Med 2003; 42 (04) 371-5.
- 48 Jones MR. “Computers can land people on Mars, why can’t they get them to work in a hospital?” Implementation of an Electronic Patient Record System in a UK Hospital. Methods Inf Med 2003; 42 (04) 410-5.
- 49 Okkes IM, Groen A, Oskam SK, Lamberts H. Advantages of long observation in episode-oriented electronic patient records in family practice. Methods Inf Med 2001; 40 (03) 229-35.
- 50 Jiang G, Ogasawara K, Endoh A, Sakurai T. Comparison of computer-based information support to clinical research in Chinese and Japanese hospitals: a postal survey of clinicians’ views. Methods Inf Med 2002; 41 (02) 141-6.
- 51 Knottnerus JA. Role of the electronic patient record in the development of general practice in The Netherlands. Methods Inf Med 1999; 38 4-5 350-4.
- 52 Weir CR, Hurdle JF, Felgar MA. et al. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med 2003; 42 (01) 61-7.
- 53 Williams JG. Measuring the completeness and currency of codified clinical information. Methods Inf Med 2003; 42 (04) 482-8.
- 54 Van Der Ploeg I. Positioning the patient: normative analysis of electronic patient records. Methods Inf Med 2003; 42 (04) 477-81.
- 55 Bludau HB, Wolff A, Hochlehnert AJ. Presenting XML-based medical discharge letters according to CDA. Methods Inf Med 2003; 42 (05) 552-6.
- 56 Brandner R, van der Haak M, Hartmann M, Haux R, Schmucker P. Electronic signature for medical documents-- integration and evaluation of a public key infrastructure in hospitals. Methods Inf Med 2002; 41 (04) 321-30.
- 57 Duftschmid G, Wrba T G, all W, Dorda W. The strategic approach of managing healthcare data exchange in Austria. Methods Inf Med 2004; 43 (02) 124-32.
- 58 Maglaveras N, Chouvarda I, Koutkias V, Meletiadis S, Haris K, Balas EA. Information technology can enhance quality in regional health delivery. Methods Inf Med 2002; 41 (05) 393-400.
- 59 Maglaveras N, Iakovidis I, de Groen PC. Regional Health Information Networks and telematics applications in a user friendly information society. Methods Inf Med 2002; 41 (05) 357-9. No abstract available
- 60 Pangalos G, Mavridis I, Ilioudis C, Georgiadis C. Developing a Public Key Infrastructure for a secure regional e-Health environment. Methods Inf Med 2002; 41 (05) 414-8.
- 61 Knaup P, Frey W, Haux R, Leven FJ. Medical informatics specialists: what are their job profiles? Results of a study on the first 1024 medical informatics graduates of the Universities of Heidelberg and Heilbronn. Methods Inf Med 2003; 42 (05) 578-87.
- 62 Kluge EH. Medical narratives and patient analogs: the ethical implications of electronic patient records. Methods Inf Med 1999; 38 4-5 253-9.
- 63 Papagounos G, Spyropoulos B. The multifarious function of medical records: ethical issues. Methods Inf Med 1999; 38 4-5 317-20.
- 64 Ammenwerth E, Haux R, Kulikowski C. et al. Medical informatics and the quality of health: new approaches to support patient care. Methods Inf Med 2003; 42 (02) 185-9.
- 65 Ball MJ, Garets DE, Handler TJ. Leveraging information technology towards enhancing patient care and a culture of safety in the US. Methods Inf Med 2003; 42 (05) 503-8.
- 66 Dorda W, Gall W, Duftschmid G. Clinical data retrieval: 25 years of temporal query management at the University of Vienna Medical School. Methods Inf Med 2002; 41 (02) 89-97.
- 67 Huske-Kraus D. Text generation in clinical medicine – a review. Methods Inf Med 2003; 42 (01) 51-60.
- 68 Kuhn KA, Giuse DA. From hospital information systems to health information systems. Problems, challenges, perspectives. Methods Inf Med 2001; 40 (04) 275-87.
- 69 Kulikowski CA. The micro-macro spectrum of medical informatics challenges: from molecular medicine to transforming health care in a globalizing society. Methods Inf Med 2002; 41 (01) 20-4.
- 70 Moorman PW, van der Lei J. An inventory of publications on electronic patient records. Methods Inf Med 1999; 38 4-5 294-7.
- 71 Moorman PW, van der Lei J. An inventory of publications on computer-based medical records: an update. Methods Inf Med 2003; 42 (03) 199-202.
- 72 van der Lei J. Closing the loop between clinical practice, research, and education: the potential of electronic patient records. Methods Inf Med 2002; 41 (01) 51-4.
- 73 Safran C, Sands DZ, Rind DM. Online medical records: a decade of experience. Methods Inf Med 1999; 38 4-5 308-12.