Healthc Inform Res.  2012 Mar;18(1):10-17. 10.4258/hir.2012.18.1.10.

The Development of Medical Record Items: a User-centered, Bottom-up Approach

• Kim Y
• Park H
• Kim HG
• Kim YO

• KMID: 2166613
• DOI: http://doi.org/10.4258/hir.2012.18.1.10

Abstract

OBJECTIVES
Clinical documents (CDs) have evolved from traditional paper documents containing narrative text information into the electronic record sheets composed of itemized records, where each record is expressed as an item with a specific value. We defined medical record (MR) items to be information entities with a specific value. These entities were then used to compile form-based clinical documents as part of an electronic health record system (EHR-s).
METHODS
We took a reusable bottom-up developmental approach for the MR items, which provided three things: efficient incorporation of the local needs and requirements of the medical professionals from various departments in the hospital, comprehensive inclusion of the essential concepts of the basic elements required in clinical documents, and the provision of a structured means for meaningful data entry and retrieval. This paper delineates our experiences in developing and managing medical records at a large tertiary university hospital in Korea.
RESULTS
We collected 63,232 MR items from paper records scanned into 962 CDs. The MR item database was constructed using 13,287 MR items after removing redundant items. During the first year of service users requested changes to be made to 235 (1.8%) attributes of the MR items and also requested the additional 9,572 new MR items. In the second year, the attributes of 70 (0.5%) of the existing MR items were changed and 3,704 new items were added. The number of registered MR items increased by 72.0% in the first year and 27.9% in the second year.
CONCLUSIONS
The MR item concept provides an easier and more structured means of data entry within an EHR-s. By using these MR items, various kinds of clinical documents can be easily constructed and allows for medical information to be reused and retrieved as data. The success of the use of MR items in a large tertiary university hospital system provides evidence that verifies our approach as being an efficient means of user-oriented and structured data entry, enabling the easy reuse of medical records.

Keyword

Medical Record; Electronic Health Record

MeSH Terms

Electronic Health Records
Electronics
Electrons
Medical Records

Figure

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  Figure 1 Hierarchical list of medical record items.

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  Figure 2 Similarity or identity checking.

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  Figure 3 Merge of redundant medical record items into a single item.

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  Figure 4 Grid arrangement. MR: medical record.

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  Figure 5 Systematized Nomenclature of Medicine (SNOMED) and terminology attributes.

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  Figure 6 Creation of electronic clinical documents. (A) Paper-based clinical document, (B) collection of medical record items and definition of attribute, (C) clinical document.

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  Figure 7 Changes in medical record items over time.

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