The proactive medical record

Abstract

In this paper the results are presented from recent developments to increase the role of the HISCOM integrated hospital information system to support direct patient care. This process has resulted in an operational Electronic Obstetric Record System (EVS) and the introduction of a generic system (MDS) to document the medical care process starting in the outpatient clinics. These systems are based on a model of the clinical care process, agreed upon by clinicians. The EVS replaces the conventional paper record and was accepted mainly by the way the EVS follows and supports the care process. The main contribution is the completeness, the availability, and the support of the care related processes like scheduling next appointments and examinations, the reporting and the automatic creation of letters. The MDS approach addresses the issue of providing kernel information by episode about the care process to clinicians and managers. The MDS is based on the episode concept, which is not restricted to the outpatient departments, but can also be applied hospital wide, and even across the boundaries of the hospital. In this paper the categorisation of ‘a proactive medical record’ will be introduced, and the potential benefits of an integrated approach to the electronic medical record (EMR) will be addressed.