The Computer-Based Clinical RecordWhere Do We Stand?

Editorials15 November 1993The Computer-Based Clinical RecordWhere Do We Stand?G. Octo Barnett, MD, Robert A. Jenders, MD, and Henry C. Chueh, MDG. Octo Barnett, MDLaboratory of Computer Science, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114., Robert A. Jenders, MDLaboratory of Computer Science, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114., and Henry C. Chueh, MDLaboratory of Computer Science, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-119-10-199311150-00014 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The practice of medicine depends on how we record, process, retrieve, and communicate information. Physicians are often frustrated with the inadequacies and duplication of the existing paper-based medical record and with the time wasted in locating medical information. The recognition of the need for more comprehensive and available documentation of patient care is not new. In her 1863 book Notes on a Hospital, Florence Nightingale wrote, In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. If they ...References1. Nightingale F. Notes on Hospitals. London: Longmans, Green and Company; 1863:176. Google Scholar2. Dick RS, Steen EB, eds. Institute of Medicine (U.S.) Committee on Improving the Patient Record. The computer-based patient record: an essential technology for health care. Washington, D.C.: National Academy Press; 1991. Google Scholar3. van der Lei J, Duisterhout JS, Westerhof HP, van der Does E, Cromme PV, Boon WM, et al. The introduction of computer-based patient records in the Netherlands. Ann Intern Med. 1993; 119:1036-41. Google Scholar4. McDonald CJ, Blevins L, Tierney WM, Martin DK. The Regenstrief medical records. MD Comput. 1988; 5:34-47. Google Scholar5. Bleich HL, Safran C, Slack WV. Departmental and laboratory computing in two hospitals. MD Comput. 1989; 6:149-55. Google Scholar6. Hendrickson G, Anderson RK, Clayton PD, Cimino J, Hripcsak GM, Johnson SB, et al. The integrated academic information management system at Columbia-Presbyterian Medical Center. MD Comput. 1992; 9:35-42. Google Scholar7. Stead WW, Hammond WE. Computer-based medical records: the centerpiece of TMR. MD Comput. 1988; 5:48-62. Google Scholar8. Barnett GO. The application of computer-based medical-record systems in ambulatory practice. N Engl J Med. 1984; 310:1643-50. Google Scholar9. Schoenbaum S, Barnett GO. Automated ambulatory medical records systems. An orphan technology. Int J Technol Assess Health Care. 1992; 8:598-609. Google Scholar10. Teich JM, Geisler MA, Cimerman DE, Frank AD, Glaser JP. Design considerations in the BWH ambulatory medical record: features for maximum acceptance by clinicians. In: Miller RA, ed. Proceedings of the Fourteenth Annual Symposium on Computer Applications in Medical Care. New York: IEEE Press; 1990:735-9. Google Scholar11. American Society for Testing and Materials. Standard guide for description for content and structure of an automated primary record of care. Standard number E 1384. Philadelphia: ASTM; 1991. Google Scholar12. McDonald CJ, Hammond WE. Standard formats for electronic transfer of clinical data. Ann Intern Med. 1989; 110:333-5. Google Scholar13. McDonald CJ, Tierney WM. Computer-stored medical records. Their future role in medical practice. JAMA. 1988; 259:3433-40. Google Scholar14. Shortliffe EH, Tang PC, Detmer DE. Patient records and computers (Editorial). Ann Intern Med. 1991; 115:979-81. Google Scholar15. United States. General Accounting Office. Automated Medical Records: Leadership Needed to Expedite Standards Development: report to the Chairman/Committee on Governmental Affairs, U.S. Senate. Washington, D.C.: USGAO/IMTEC-93-17; April 1993. Google Scholar16. Nowlan WA, Rector AL, Kay S, Goble CA, Horan B, Howkins TJ, Wilson A. PEN&PAD: a doctors' workstation with intelligent data entry and summaries. In Miller RA, ed. Proceedings of the Fourteenth Annual Symposium on Computer Applications in Medical Care. New York: IEEE Press; 1990:941-2. Google Scholar17. Scherrer JR, Baud RH, Hochstrasser D, Ratib O. An integrated hospital information system in Geneva. MD Comput. 1990; 7:81-9. Google Scholar Author, Article, and Disclosure InformationAffiliations: Laboratory of Computer Science, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114.Corresponding Author: G. Octo Barnett, MD, Laboratory of Computer Science, Massachusetts General Hospital, 50 Staniford Street, 5th floor, Boston, MA 02114. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Introduction of Computer-based Patient Records in the Netherlands Johan van der Lei , Joop S. Duisterhout , Henk P. Westerhof , Emiel van der Does , Paul V. M. Cromme , Wilfried M. 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An audit on prescription items and x-ray requestsClinical data systems, part 2: components and techniquesUse of open standards to implement health maintenance guidelines in a clinical workstation 15 November 1993Volume 119, Issue 10Page: 1046-1048KeywordsComputer softwareComputersComputing systemsDrugsElectronic medical recordsHealth careInformation retrievalInformation technologyResearch laboratoriesSoftware tools Issue Published: 15 November 1993 Copyright & PermissionsCopyright © 1993 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...