• H Stam and A M van Ginneken.
• Department of Medical Informatics, Faculty of Medicine, Erasmus University, Rotterdam, The Netherlands.
• Medinfo. 1995 Jan 1; 8 Pt 2: 1666.

AbstractShortcomings of Paper Medical Records have been well recognized: limited readability, completeness, consistency, availability, structure, etc. Although electronic storage solves the problems of availability and legibility, data analysis and decision support require more than free text in electronic form. Although many information systems contain diagnoses and lab data in coded form, findings have often been left to free text. Even though the shortcomings of paper records are more pronounced in specialized care than in primary care, Dutch general practitioners have proven far more receptive to the use of computerized records. Specialists are very diverse in their domains of expertise and usually work in a complex environment: no single record would satisfy them all. Our objective is to support the specialist with the acquisition of patient data in a structured format with emphasis on history and physical exam. Important considerations have been that it will benefit physician and patient if record data can be shared, and that every specialist can record both data within, as well as outside, his domain of expertise. The philosophy of our Computer-based Patient Record model is based on two main principles: 1) A 'mother' record that can be extended with specialized subrecords. 2) A structure that supports flexible retrieval, efficient data entry and data analysis. The mother record contains information that all records have in common, but also offers the option of entering information, which has not been modeled in a subrecord. The 'face' of the mother record is the patient profile which offers the physician an overview of the status of the patient on any specified date. The profile includes diagnoses, medication, test results, and dates of previous visits. From this overview, the physician can directly access the subrecords, zoom in on data, or call another view. To avoid abrupt change in the daily routine of the physician, the interface allows the user to keep records in a rather conventional way, i.e., as free text. Yet, the interface constantly brings to attention the benefits of structured data, which will stimulate the physician to enter the data in a structured way; when most fields in the patient profile are empty, such as medication and past history, he may regret to have only entered free text in a 'summary' field. The mother record and a specialized record for the out-patient clinic of cardiac failure have been developed with the Department of Internal Medicine and the Thorax Centre of the Academic Hospital Rotterdam. The demonstration will show the versatility of both records. The application runs on a Unix platform with the use of an Interbase DBMS, OSF-Motif windows, and the Hermes kernel.

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