Slack has suggested that one way forward is to separate the clinical and administrative uses of computers. In contrast, most US doctors dictate verbose records, which are less amenable to structured record keeping. Lloyd George's system is scarcely fit for its purpose, but the consequent brevity of notes facilitated computerisation with small computers. Hospital case notes are more voluminous than traditional British general practice paper records, which are normally maintained on small cards, named after the politician who introduced them more than 90 years ago. This type of dynamic formatting contrasts with paper records, which are formatted at the time that they are written. Users find what they want in a complex patient record (which may have thousands of entries) by displaying information on the screen using multiple views by date, problem, topic, or reminder prompt. 8 In Britain today, few hospitals use POMR, although it is widely used in computerised general practices, having been introduced as an integral part of the Abies-Meditel System 5 in 1987. Many efforts have been made to improve the structure and organisation of patient records, notably Weed's problem oriented medical record (POMR), originally developed nearly 35 years ago for use in hospitals. For example, the mode of information use is different in intensive care, on inpatient wards, at outpatient clinics, and in general practice surgeries with regard to variables such as the volume and half-life of data, the need for rapid response, and the value of decision support tools and integration with medical devices. Hospital medicine has complex workflow, job specialisation, and division of labour, which creates complex and diverse patterns of information use. Hospital doctors work in teams and in many places-any ward where they have patients, outpatient clinics, offices, laboratories, and libraries, often at more than one hospital, and from private consulting rooms. General practitioners work mostly in their consulting room, normally seeing one patient at a time on a one to one basis, and their computer systems are designed for a limited number of uses. The unresolved issue is that patient record architectures needed to support general practices and hospital-wide applications are not commensurable. This helps to explain why most successful patient record systems have been limited to situations where the scope of use is well understood, such as general practices 6 or individual clinical units in hospitals. Each group has its own audit, quality assurance, decision support, and other requirements. The Department of Health recognises 62 clinical specialties for doctors, with a similar number of nursing, scientific, therapeutic, and administrative specialisations. ![]() 5 Furthermore, each group of staff has specific needs of its own. These uses have been classified as clinical management, clinical administration, clinical services, and general management. ![]() However, patient records serve an enormous range of tasks, including direct patient care, preventive care (call, recall, and follow up), clinical decision support, audit and accountability, legal evidence, management and financial control, clinical trials, research, and comparisons (local, national, and international). ![]() The present generation of computer based patient record systems can handle only a limited number of predetermined tasks. The human brain is far more flexible than any computer program and can cope with an unlimited number of uses. 3Ī key difference between using paper and computer based records is that the users of paper records do all of the work: “To use a paper-based patient record, the reader must manipulate data, either mentally or on paper, to glean important clinical information.” 4 The computer should relieve readers of this effort, but this points to the root cause of the difficulty. The Audit Commission estimates that 25% of hospital staff time is spent collecting data and using information, yet the quality of data being collected is a cause for concern. The requirement is easily stated-to provide the right information, to the right person, at the right place, at the right time, efficiently and safely. Computer based patient records have long been seen as a goal of healthcare informatics, but the reality has proved elusive.
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