Power of expression in the electronic patient record: structured data or narrative text?
Power of expression in the electronic patient record: structured data or narrative text?
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DOI：
10.1016/s1386-5056(00)00079-4
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发表时间：
2000-09-01
影响因子：
4.9
通讯作者：
Planche, P
中科院分区：
文献类型：
--
作者：
Lovis, C;Baud, RH;Planche, P
本文介绍了作者在一家大型教学医院开发和使用以文档为中心的电子病历（EPR）的经验。以文件为中心的EPR的发展始于一系列关键假设的制定，以促进最佳医疗实践的延续以及EPR的实施和使用。另一种更传统的方法-以数据为中心的EPR -与以文档为中心的EPR进行了比较。各种好处和陷阱进行了讨论。最后，选择是在一个紧密联系的系统中提供这两种解决方案。对结合了以文档和数据为中心的方法的EPR的需求反映了对未来医疗记录的更一般性讨论。通常，对结构化数据的需求与对自由文本和表达能力的需求相冲突。评估这一初步决定的后果并不容易。然而，在《扩大生产者责任报告》实施后改变其基础是困难和昂贵的。因此，在一个特定的医院选择正确的方向需要一个广泛的讨论。(C)2000爱思唯尔科学爱尔兰有限公司保留所有权利。
This paper presents the authors' experience with the development and use of a document-centered electronic patient record (EPR) in a large teaching hospital. The development of the document-centered EPR began with the formulation of a set of critical hypotheses to facilitate both the continuation of the best medical practice and the implementation and use of the EPR. An alternate and more conventional approach - the data-centered EPR - is compared with the document-centered EPR. Various benefits and pitfalls are discussed. Finally, the choice was to offer both solutions in a tightly linked system. The need for an EPR which combines the document and data centered approaches is a reflection of the more general discussion of what the medical record will be in the future. All too often, the need for structured data conflicts with the need for free texts and the power of expression. It is not easy to evaluate the consequences of this initial decision. However, changing the foundations of the EPR after its implementation is difficult and expensive. Therefore, the selection of the correct orientation in a given hospital requires a broad-based discussion. (C) 2000 Elsevier Science Ireland Ltd. All rights reserved.