The helpful patient record system: problem oriented and knowledge based

Abstract

In contrast to existing computerized patient record systems, which merely offer static functionality for storage and presentation, a helpful patient record system is a problem-oriented, knowledge-based system which provides the clinician with situation-specific information from the patient record, relevant to the activity within the patient care process. We suggest extending the data model of current patient record systems with (1) knowledge for recognizing and interpreting care situations, (2) knowledge of how clinicians work and what information they need, and (3) means to rank information according to its relevance in a given situation. We present a framework that enables representation of three prerequisite features for a future helpful patient record system: the primary care workflow process, the problem-oriented information model, and means to identify relevant information to the care process and medical decisions.