Subscribe to RSS
A Framework for Modelling the Electronic Medical Record
08 February 2018 (online)
This paper presents a model for an electronic medical record which satisfies the requirements for a faithful and structured record of patient care set out in a previous paper in this series. The model underlies the PEN & PAD clinical workstation, and it provides for a permanent, completely attributable record of patient care and the process of medical decision making. The model separates the record into two levels: direct observations of the patient and meta-statements about the use of observations in decision making and the clinical dialogue. The model is presented in terms of “descriptions” formulated in the Structured Meta Knowledge (SMK) formalism, but many of its features are more general than the specific implementation. The use of electronic medical records based on the model for decision support and the analysis of aggregated data are discussed along with potential use of the model in distributed information systems.
Key-wordsMedical Record - Information Models - Standards - Problem-Oriented Medical Record - Coding Systems
1 Following the convention from the European Workshop on Open Systems (EWOS). PT007 on Medical Informatics we use the term “clinician” for any physician, nurse or other health care provider.
- 1 Rector AL, Nowlan WA, Kay S. Foundations for an electronic medical record. Meth Inform Med 1991; 30: 179-86.
- 2 Nowlan WA, Kay S, Rector AL, Horan B, Wilson A. A multi-lingual patient care workstation based on a unified representation of the medical record and medical knowledge. In: Proceedings of MIE 91. Lecture Notes in Medical Informatics 45. Adlassnig KP, Grabner G, Bengtsson S, Hansen R. (eds). Berlin: Springer; 1991: 1043-5.
- 3 Horan B, Nowlan WA, Wilson A. et al. Intelligent clinical data entry for general practice: the PEN Project. In: Proceedings of Current Perspectives in Health Computing CP90. De Glanville H, Roberts J. (eds). Brit Healthcare Comp; 1990. BJHC Books: 84-91.
- 4 Rector AL, Goble CA, Horan B. et al. Shedding light on patients’ problems: integrating knowledge based systems into medical practice. In: Proceedings of the Ninth European Conference on Artificial Intelligence, ECAI 90. Aiello LC. (ed). Stockholm: Pitman Publishing; 1990: 531-4.
- 5 Nowlan WA, Rector AL, Kay S, Horan B, Wilson A. A patient care workstation based on a user centred design and a formal theory of medical terminology: PEN & PAD and the SMK Formalism. In: Fifteenth Annual Symposium on Computer Applications in Medical Care. Clayton PD. (ed). New York: McGraw-Hill; 1991: 855-7.
- 6 Kay S, Rector AL, Nowlan WA. et al. What should we mean by an “Electronic Medical Record”. In: Medical Informatics Europe 1991. Lecture Notes in Medical Informatics No. 45. Adlassnig K-P, Grabner G, Bengtsson S, Hansen R. (eds). Berlin: Springer; 1991: 132-9.
- 7 Van der Lei J, Westerman RF, Mosseveld BMTh. Critiquing based on automated medical records: An evaluation of HYPER-CRITIC. In: Medical Informatics in Europe 1990. Lecture Notes in Medical Informatics No. 40. O’Moore R, Bengtson S, Bryant JR, Bryden JS. (eds). Berlin: Springer; 1990: 369-74.
- 8 Rector AL, Kay S. Descriptive models for medical records and data interchange. In: Proceedings of MEDINFO 89. Barber B, Cao D, Qin D, Wagner G. (eds). Amsterdam: North-Holland Publ Comp; 1989: 230-4.
- 9 Rector AL. A structured skeleton for medical knowledge representation. Biomed Meas Inform Control 1979; 01: 197-200.
- 10 Rector AL, Nowlan WA, Kay S. Unifying medical information using an architecture based on descriptions. In: Proceedings of the 14th Annual Symposium on Computer Applications in Medical Care. Miller RA. (ed). Los Alamitos Cal: IEEE Computer Society Press; 1990: 190-4.
- 11 Nowlan WA, Rector AL. Medical knowledge representation and predictive data entry. In: Proceedings of AIME 91. Lecture notes in Medical Informatics No. 44. Stefanelli M, Hasman A, Fieschi M, Talmon J. (eds). Berlin: Springer; 1991: 105-6.
- 12 Rector AL, Nowlan WA, Kay S. Conceptual Knowledge: the core of medical information systems. In: MEDINFO-92. Lun KC, Degoulet P, Piemme TE, Rienhoff O. (eds). Amsterdam: North Holland Publ Comp; 1992: 1420-6.
- 13 Kay S, Rector AL, Nowlan WA. Structure for Classification in Primary Health Care. Standardization in Europe on Semantical Aspects of Medicine (SESAME). Brussels: AIM Project A1031; Deliverable 9, 1990
- 14 Leung YN, Kay S. 4GLs, change and clinical information systems. Proceedings of the Fifth International Conference on System Science in Health Care. Prague, 1992: 1242-4.
- 15 Pauker SG, Gorry GA, Kassirer JP. Toward the simulation of clinical cognition: Taking a present illness by computer. Amer J Med 1976; 60: 981-96.
- 16 Shortliffe EH. Knowledge-based systems in medicine. In: Medical Informatics Europe 1991. Lecture Notes in Medical Informatics No. 45. Adlassnig K-P, Grabner G, Beng-stsson S, Hansen R. (eds). Berlin: Springer; 1991: 5-9.
- 17 GALEN, General Architecture for Language Encyclopaedias and Nomenclatures in Medicine. Project 2012, AIM Initiative, EC. Technical Annex. (Details available from the authors.)