A Framework for Modelling the Electronic Medical Record

Clinical care increasingly requires healthcare professionals to access patient record information that may be distributed across multiple sites, held in a variety of paper and electronic formats, and represented as mixtures of narrative, structured, coded and multimedia entries. A longitudinal person-centred electronic health record (EHR) is a much-anticipated solution to this problem, but the challenge of providing clinicians of any profession or speciality with an integrated view of the complete health and healthcare history of each patient under their care has so far proved difficult to meet. This need is now widely recognised to be a major obstacle to the safe and effective delivery of health services, by clinical professions, by health service organisations and by governments internationally.From an academic vision in the late 1980s the EHR has evolved to become centre stage in the national health informatics strategies of most European countries, and internationally. Health services and vendors are now actively establishing national infrastructures to enable the communication of high volumes of clinical information, and incorporating the necessary security features to protect these data.International research has highlighted the clinical, ethical and technical requirements that need to be met in order to effect this transition. There is a need for interoperability standards that can permit clinical computer systems to share health record data whilst preserving faithfully the clinical meaning of the individual authored contributions within it. Concerns about protecting the confidentiality of sensitive personal information must also be addressed if consumer confidence is to be maintained when EHRs are widely accessible.There are many challenges and cultural changes facing the safe and effective delivery of contemporary healthcare services:• the requirement to limit healthcare costs and to optimise resource utilization,• the shift of care from specialist centres to community settings,• the requirement to deliver evidence-based and quality-assured care,• the growth of consumerism and patient active participation in health care,• equity of access and public involvement in priority setting,• an increasing complexity of healthcare provision,• an increasingly distributed and mobile clinical workforce,• changes in the working patterns and accountability of healthcare professionals,• the overwhelming growth of medical knowledge,• a critical reliance upon comprehensive patient records,• increasing concerns about the confidentiality of patient records.

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A Framework for Modelling the Electronic Medical Record

Cited by 54 publications

References 8 publications

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