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A new medical record will make it easier to be a doctor

Postet 29.11.2016  av Oddny J. Johnsen


- The medical record system of the future will find guidelines and provide support for decisions, remind the doctor about all the considerations she should make, and which laws and regulations apply to different cases, according to a researcher.

In the future, the electronic medical record will assist the doctor in a completely different way than today.

- Today's electronic medical record is really just the old paper system moved over to the computer, says researcher Rune Pedersen at the Norwegian Centre for E-health Research.

- The medical record system of the future will find guidelines and provide support for decisions, remind the doctor about all the considerations she should make, and which laws and regulations apply to different cases.

The idea is that the system will give recommendations to the doctor as to the best methods that suit this particular patient.

The doctor will tick rather than write

- There is already a lot of exciting progress. Businesses are now developing a new electronic medical record, with a functionality we have never seen before. Some functionality is already in use and shows the outlines of what future solutions may include, says Pedersen.

- The structuring of health data, for instance.

Structuring of health data means that information about patients are added to the record in a predefined structure, which is equal for all records. This makes the information both searchable and comparable.

The counterpart to this would be data recorded as free text, where currently only a human being and not a computer program, can understand the text.

When the electronic medical record is structured, clinical health professionals can extract relevant information quickly and easily, while they receive support for further treatment.

The information is divided into different types

New data systems are created in open source, and are based on something called archetypes.

- Archetypes are predefined models that make it possible to structure health data. A clinical concept could be blood pressure. The Norwegian archetype committee, consisting of clinicians and technologists, agree on what is included in a blood pressure, such as the device, size of the cuff, which position the patient is in and so on, which may contribute to influencing a blood pressure reading.

- When systems use the same archetypes, the data is understood by the systems. This is currently not the case, where we are still exchanging free text that must be read by another human being to be understood. By using archetypes, we can search and reuse data in the same system.
 

The patient also contributes

For Christmas in 2015, all hospital patients under Northern Norway Regional Health Authority were given the opportunity to log in and read their own medical record. This is now also being introduced in Western Norway Regional Health Authority.

Pedersen believes that the electronic medical records of the future provide greater opportunities for the patients themselves to register health data in the same way that doctors can in the current core journal.

Core journal is an online medical record system where doctors collect important health information about you as a patient, and it should function as a warning system across regions and hospitals. In the core journal, there are no documents, only critical information, personal information, medication and records of visits.

The medical record is documentation of all medical treatment you have received, such as case summaries, blood test results, notes and so on.

In addition to the patients themselves being able to register health information in the new medical record, extracting information will also be easier. This means that extracting data to quality registers and others requiring documentation and reports should be carried out automatically.

- Today, health professionals usually register the same information on a patient two, three and four times, says Pedersen.

Healthy scepticism

- Now that we realise our opportunity to provide structured data, a discussion arises as to how much we should structure, says Rune Pedersen.

He believes that many are afraid of everyday routines where they are forced to tick the different information in boxes.

- We must be critical of what should be structured and why. That is a very difficult job, while development in projects have provided some examples of how structured data can be used, the researcher says.

- We have progressed considerably since electronic medical records were first introduced, but many aspects are still visions.

Reference

Rune Pedersen: The Value of Clinical Information Models and Terminology for Sharing Clinical Information. eTELEMED 2016, The Eighth International Conference on eHealth, Telemedicine and Social Medicine. 2016. ISBN 978-1-61208-470-1.

Gro-Hilde Ulriksen: Consensus on Norwegian archetypes. Studies in Health Technology and Informatics 2016 ;Volum 221. s. 131-131.