An Ideal System for Medical Doctors to Record and Display Patients' Histories with Computerized Medical Record Systems

DOI
  • Nakahara Y
    Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center
  • Itoh H
    Medical Information Systems Division, National Hospital Organization Himeji Medical Center
  • Kohno H
    Medical Information Systems Division, National Hospital Organization Himeji Medical Center
  • Nakagawa K
    Medical Information Systems Division, National Hospital Organization Himeji Medical Center
  • Suma A
    Medical Information Systems Division, National Hospital Organization Himeji Medical Center

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Other Title
  • 電子カルテにおける診療情報の入力・表示様式　—医師が考える理想—

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Background: Grasping a patient's history with computerized medical record systems is not necessarily easier than with paper-based medical records. We proposed an ideal way of recording and displaying patients' histories from the standpoint of medical doctors.<br/> Methods: We asked doctors about their opinions on the ideal medical records system. In order to realize their vision of the ideal system, we developed an assist system that works with medical record systems as the backbone. We tested the usability of the assist system with an experiment to grasp patients' histories.<br/> Results: Based on the interviews with the doctors, we concluded that the ideal medical system consists of the following: the system provides up-to-date summaries of the entire medical history of patients without causing additional work for the doctors in charge; each diagnosis is accompanied by several related information, such as TNM classification and histological type for lung cancers; treatment histories should include information on all kinds of therapies that the patient received (drug therapy, surgical operation, radiotherapy, and so on), the therapies can be classified by the diseases of concern such as neoplastic diseases or infectious diseases, and they can be displayed with the laboratory data in chronological order to help the physicians evaluate the therapeutic effect of each therapy. In the experiment with doctors, this assist system significantly shortened the amount of time required for understanding patients' medical histories and promoted the accuracy of their understanding.<br/> Conclusions: It was ascertained that improvement of the system of recording and displaying patients' histories would contribute to the efficacy and accuracy of medical practice.

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