An experimental electronic patient record for stroke patients. Part 2: System description

This article presents an electronic patient record (EPR) for stroke patients. At the neurology department of the Maastricht University Hospital, coordination and communication of the multidisciplinary team for stroke patients is intended to be supported by an EPR. Existing, structured, paper nursing and medical records served as a starting point for the development of the EPR. In close cooperation with future users, the database structure, and data entry and data retrieval aspects of the user interface were adapted to the domain of stroke. The result is a combined electronic medical and nursing record that has potential to improve record keeping and to truly support daily routines. The challenges encountered in the development process were maintaining continuous user involvement and conflicting points of view regarding the relevance of clinical data. Conclusively, we state that intensive user participation improved the EPR, coupling with the existing hospital information system and other systems will be advantageous and the fact that the paper records were structured in advance will smooth the unavoidable changes in work patterns.

[1]  J F Fries,et al.  Alternatives in Medical Record Formats , 1974, Medical care.

[2]  E. B. Steen,et al.  The Computer-Based Patient Record: An Essential Technology for Health Care , 1992, Annals of Internal Medicine.

[3]  E Nygren,et al.  Reading the medical record. I. Analysis of physicians' ways of reading the medical record. , 1992, Computer methods and programs in biomedicine.

[4]  M A Hebert,et al.  Impact of IT on Health Care Professionals: Changes in Work and the Productivity Paradox , 1998, Health services management research.

[5]  A. Strauss Social Organization of Medical Work , 1985 .

[6]  Michael M. Wagner,et al.  Review: Accuracy of Data in Computer-based Patient Records , 1997, J. Am. Medical Informatics Assoc..

[7]  P. C. Tang,et al.  Research Paper: Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions , 1999, J. Am. Medical Informatics Assoc..

[8]  A Hasman,et al.  An experimental electronic medical-record system with multiple views on medical narratives. , 1997, Computer methods and programs in biomedicine.

[9]  E. Shortliffe,et al.  An analysis of physician attitudes regarding computer-based clinical consultation systems. , 1981, Computers and biomedical research, an international journal.

[10]  Ronald E. Rice,et al.  Social worlds, individual differences, and implementation: Predicting attitudes toward a medical information system , 1991, Inf. Manag..

[11]  J Dudeck,et al.  Stepwise Evaluation of Information Systems in an University Hospital , 1999, Methods of Information in Medicine.

[12]  Donald A. Norman,et al.  User Centered System Design , 1986 .

[13]  C. Aydin Occupational adaptation to computerized medical information systems. , 1989, Journal of health and social behavior.

[14]  Arie Hasman,et al.  An experimental electronic patient record for stroke patients. Part 1: Situation analysis , 2000, Int. J. Medical Informatics.

[15]  Fred D. Davis Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology , 1989, MIS Q..

[16]  Q. Whiting-O'Keefe,et al.  A computerized summary medical record system can provide more information than the standard medical record. , 1985, JAMA.

[17]  B. Kaplan The Influence of Medical Values and Practices on Medical Computer Applications , 1982 .

[18]  Arie Hasman,et al.  The granularity of medical narratives and its effect on the speed and completeness of information retrieval. , 1998, Journal of the American Medical Informatics Association : JAMIA.

[19]  Byron E. Bork,et al.  Medical Records, Medical Education, and Patient Care , 1975 .

[20]  Arie Hasman,et al.  An experimental electronic patient record for stroke patients , 1999, MIE.

[21]  P C Tang,et al.  Major issues in user interface design for health professional workstations: summary and recommendations. , 1994, International journal of bio-medical computing.

[22]  Bonnie Kaplan,et al.  Review: Addressing Organizational Issues into the Evaluation of Medical Systems , 1997, J. Am. Medical Informatics Assoc..

[23]  Michael J. Papa,et al.  Communication Network Patterns and Employee Performance With New Technology , 1990 .

[24]  Astrid M. van Ginneken,et al.  Research Paper: Evaluation of Reporting Based on Descriptional Knowledge , 1995, J. Am. Medical Informatics Assoc..

[25]  T. S. Startsman,et al.  The attitudes of medical and paramedical personnel toward computers. , 1972, Computers and biomedical research, an international journal.

[26]  H J Tange,et al.  The paper-based patient record: is it really so bad? , 1995, Computer methods and programs in biomedicine.

[27]  Charles P. Friedman,et al.  Development and initial validation of an instrument to measure physicians' use of, knowledge about, and attitudes toward computers. , 1998, Journal of the American Medical Informatics Association : JAMIA.

[28]  D E Forsythe,et al.  New bottles, old wine: hidden cultural assumptions in a computerized explanation system for migraine sufferers. , 1996, Medical anthropology quarterly.

[29]  Sammy W. Pearson,et al.  Development of a Tool for Measuring and Analyzing Computer User Satisfaction , 1983 .

[30]  A Savill,et al.  Information in practice Integrated record keeping as an essential aspect of a primary care led health service , 1998 .

[31]  R. Rice,et al.  Bringing social worlds together: computers as catalysts for new interactions in health care organizations. , 1992, Journal of health and social behavior.

[32]  Ben Shneiderman,et al.  Designing The User Interface , 2013 .

[33]  Charles P. Friedman,et al.  Evaluation Methods in Medical Informatics , 1997, Computers and Medicine.

[34]  James R. Lewis,et al.  IBM computer usability satisfaction questionnaires: Psychometric evaluation and instructions for use , 1995, Int. J. Hum. Comput. Interact..

[35]  B Kaplan An evaluation model for clinical information systems: clinical imaging systems. , 1995, Medinfo. MEDINFO.

[36]  Steven H. Brown,et al.  Research Paper: Changes in Physicians' Computer Anxiety and Attitudes Related to Clinical Information System Use , 1994, J. Am. Medical Informatics Assoc..

[37]  E Nygren,et al.  Reading the medical record. II. Design of a human-computer interface for basic reading of computerized medical records. , 1992, Computer methods and programs in biomedicine.

[38]  C. Barry,et al.  Information systems technology: barriers and challenges to implementation. , 1990, The Journal of nursing administration.

[39]  P. Thomas The social and interactional dimensions of human-computer interfaces , 1995 .

[40]  P. Langhorne,et al.  Do stroke units save lives? , 1993, The Lancet.

[41]  Marc Berg,et al.  Considerations for sociotechnical design: experiences with an electronic patient record in a clinical context , 1998, Int. J. Medical Informatics.