An Efficient, Clinically-Natural Electronic Medical Record System that Produces Computable Data.

Brent C James, David P Edwards, Alan F James, Richard L Bradshaw, Keith S White, Chris Wood, Stan Huff
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引用次数: 3

Abstract

Current commercially-available electronic medical record systems produce mainly text-based information focused on financial and regulatory performance. We combined an existing method for organizing complex computer systems-which we label activity-based design-with a proven approach for integrating clinical decision support into front-line care delivery-Care Process Models. The clinical decision support approach increased the structure of textual clinical documentation, to the point where established methods for converting text into computable data (natural language processing) worked efficiently. In a simple trial involving radiology reports for examinations performed to rule out pneumonia, more than 98 percent of all documentation generated was captured as computable data. Use cases across a broad range of other physician, nursing, and physical therapy clinical applications subjectively show similar effects. The resulting system is clinically natural, puts clinicians in direct, rapid control of clinical content without information technology intermediaries, and can generate complete clinical documentation. It supports embedded secondary functions such as the generation of granular activity-based costing data, and embedded generation of clinical coding (e.g., CPT, ICD-10 or SNOMED). Most important, widely-available computable data has the potential to greatly improve care delivery management and outcomes.

Abstract Image

一个有效的,临床自然电子医疗记录系统,产生可计算的数据。
目前商业上可用的电子病历系统主要产生基于文本的信息,侧重于财务和监管绩效。我们将现有的组织复杂计算机系统的方法(我们将其称为基于活动的设计)与将临床决策支持集成到一线护理交付的经过验证的方法(护理过程模型)相结合。临床决策支持方法增加了文本临床文档的结构,达到了将文本转换为可计算数据(自然语言处理)的既定方法有效工作的程度。在一项简单的试验中,为排除肺炎而进行的检查提供放射学报告,产生的所有文件中有98%以上被捕获为可计算的数据。广泛的其他内科、护理和物理治疗临床应用的用例主观上显示了类似的效果。由此产生的系统是临床自然的,使临床医生可以直接、快速地控制临床内容,而不需要信息技术中介,并且可以生成完整的临床文档。它支持嵌入式辅助功能,如生成颗粒状的基于作业的成本数据,以及嵌入式生成临床编码(例如CPT、ICD-10或SNOMED)。最重要的是,广泛可用的可计算数据具有极大改善护理提供管理和结果的潜力。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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