What Should We Mean by ‘An Electronic Medical Record’?
Development of the PEN&PAD prototype patient care workstation has made us acutely aware of the need to re-examine and analyse the basic requirements of the medical record. We present the work emerging from this analysis which we believe applies to any ‘electronic medical record’, and argue that the principal purpose of the medical record is to support direct patient care. This is a fundamentally different position to many existing medical record systems whose designs derive, explicitly or implicitly, from the need to use aggregated data. Furthermore such a view has important implications for the standardisation of the electronic medical record. The goal is to create an architecture for the medical record which is faithful to the process of patient care and useful to and usable by clinicians.
KeywordsElectronic Medical Record Aggregate Data Medical Informatics Direct Patient Care Medical Language
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