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Clinical Encounter Filters Based Data Entry of Medical Findings by Physicians
Yves A. Lussier, M.D.1,2
1 Purkinje Inc., 7333, Place des Roseraies, R. 309, Anjou, P.Q., Canada, 514-355-0888 2 Department of Family Medicine, Hôtel-Dieu of Sherbrooke Hospital, P.Q. 3 Department of Computer
ABSTRACT Physicians regularly use procedures or encounter forms to write more efficiently legible records. Clinical Encounter Filters (CEFs) are software templates of structured Medical Findings (MFs) relevant to the patient's problems. An underlying Medical Knowledge Base (MKB) contains encoded and structured MFs. The physician can point at MFs displayed by the CEF or zoom in and out of the MKB for rapid and efficient recording of more detailed MFs. The Dynamic Dialog Interface also provides the flexibility to handwrite or draw in order to complete the record using pen-based technology. The recorded MFs are therefore legible, structured, encoded and easily retrievable for patient care, automatic billing, or research. Presented at the American Medical Informatics Association 1993 Spring Congress, St-Louis, Missouri, May 9-12, 1993.
INTRODUCTION This research is based on the following hypotheses: - Medical Findings (MFs) can be expressed explicitly in structured and standard lexicons. - Physicians can use these lexicons to record a large proportion of their MFs. Other MFs can be drawn or handwritten to complete the record. Other direct data entry interfaces for physicians have been shown to use extensive lexicons [1], [2], but this model is the only one that combines disease or problem-oriented CEFs with pen-based technology [3].
DATA ENTRY DESIGN This demonstration will propose a physician data entry interface that combines data acquisition flexibility for record completeness with large proportions of encoded medical findings. Using CEFs and the underlying MKB, physicians can efficiently encode relevant MFs. Handwriting and drawings complete the record and can be related to any encoded MFs.
DISCUSSION The acceptance of Computerized Patient Records relies on their ability to efficiently record patients' data without content impoverishment [4], [5]. Recorded information has limited value unless it is structured and encoded. Encoded data can easily be retrieved for patient care, billing or research. Furthermore, standards are essential for comprehensive data exchange and reuse. On the other hand, the form of medical records is now fixed by habit and custom [5]. It has also been stressed that MFs are unique to an institution and standards limit records completeness [6]. The data entry model was successfully tested with family physicians from a variety of institutions. The preliminary results have shown that physicians records content can be encoded in structured MKB common to family physicians. In conclusion, the proposed data entry interface models meets the challenge of efficiently encoding large proportions of clinical data directly from the provider of care without information impoverishment.
Reference [1] Naeymi-Rad F, Trace D. Intelligent Medical Re- cord Entry. Proc. of the 16th SCAMC, 1992:783-4. [2] Rector AL, et al. PEN & PAD: A Doctor's Work- station with Intelligent Data Entry and Summaries. Proc. of the 14th SCAMC. ,1990: 941-2. [3] Lussier Y.A., et al. PureMD: a Computerized Patient Record Software for Direct Data Entry by Physicians Using a Keyboard-free Pen-Based portable Computer. Proc. of the 16th SCAMC, 1992:261-4. [4] Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine. The Computer-Based Patient Record. National Academy Press. Washington, D.C. 1991. [5] Levy H.A., Lawrance D.P. Data Acqusition and Computer-Based Patient Records. Aspects of the Computer-Based Patient Record. Springer-Verlag, New-York, 1992. p.125-139. [6] Benchetrit D. L'informatisation du dossier médical dans une unité de soins. Springer-Verlag, Informatique et Santé 1, 1989:100-5. © Y.A. Lussier,
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