Data from clinical notes: a perspective on the tension between structure and flexible documentation.

Will the wave finally break? A brief view of the adoption of electronic medical records in the United States

There is a broad consensus that 21st century health care will require intensive use of information technology to acquire and analyze data and then manage and disseminate information extracted from the data No area is more data intensive than the intensive care unit While there have been major improvements in intensive care monitoring, the medical industry, for the most part, has not incorporated many of the advances in computer science, biomedical engineering, signal processing, and mathematics that many other industries have embraced Acquiring, synchronizing, integrating, and analyzing patient data remain frustratingly difficult because of incompatibilities among monitoring equipment, proprietary limitations from industry, and the absence of standard data formatting In this paper, we will review the history of computers in the intensive care unit along with commonly used monitoring and data acquisition systems, both those commercially available and those being developed for research purposes

/pdf/information-technology-in-critical-care-review-of-monitoring-106dw4r36c.pdf

Information Technology in Critical Care: Review of Monitoring and Data Acquisition Systems for Patient Care and Research

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. Based on their experience rolling out an EHR system that supports multiple methods for clinical documentation, the authors recommend that documentation method selection be made on the basis of clinical workflow, note content standards and usability considerations, rather than on a theoretical need for structured data.

/pdf/generating-clinical-notes-for-electronic-health-record-32drh7xw6o.pdf

Generating Clinical Notes for Electronic Health Record Systems.

Problems and pitfalls of risk assessment in antenatal care

A computerized obstetric medical record.

The Westinghouse Voice Response System is a stand-alone hardware unit designed for automated data collection. Questions are asked in the audio mode. Responses are printed at the time of the interview and stored on magnetic tape for future retrieval. This audio system was evaluated as a method for the collection of the initial medical history. In addition, comparisons were made among three techniques of automated data collection: audio, video and paper and pencil. The audio mode of automated history taking was more effective than comparable paper and pencil and video systems in situations where the patient population was of borderline literacy. The Westinghouse Voice Response System is a viable stand-alone system for those situations in which on-line access to a computer is not available.

Evaluation of an audio mode of the automated medical history.

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A computerized obstetric medical record.

Evaluation of an audio mode of the automated medical history.