2.

User needs: Why the Paper Medical Record is still Appreciated

 as a provider of management information,

 as a source for research, or for other secondary purposes,
 the advantages of electronic medical-records systems are unques-tionable.

In 1993 we held a questionnaire survey among 85 hospital physicians to study their appreciation of
the current paper-based medical record and their needs for improvement, The ques- tionnaire
consisted of 55 statements about the entry of data.

doctors in particular want to maintain a flexible data entry facility from paper medical records. On
the other hand, also some needs for improof were indicated: the retrieval of information should be
faster, the registertration of decisions, plans, and orders in the medical record should be more
complete, and the security and confiidentity of medical data should be better guaranteed.

These results reminded us to be careful with projecting conclusions about medical-record keeping as
described in the literature, to a local situation. When considering the introduction of an electronic
medical-record system, an assessment of the users’ appreciation of the existing paper-based system
should always be part of the procedure.

3. Prototype EMR System:Design Considerations and Implementation

developed a prototype EMR system especially designed to facilitate the consultation of medical
narratives and to assess the best-suited structure for medical narratives. For the design of the
system we addressed two architectural problems:

1. The granularity of medical narratives - Medical narratives can be divided into segments of
various levels of detail.
2. The organization of medical narratives – The process of locating of relevant segments will be
influenced by the way these segments are arranged.The contribution of indexed labels to
these segments (such as source,problem, and time) can facilitate this process.

3.1 Organization of Medical Narratives

One of the advantages of an EMR is that it can present the same medical data in different
arrangements. The Maastricht EMR has two kinds of flow sheets: source-oriented and problem
oriented.

 oriented flow sheet = gambar 1

In the problem-oriented flowsheet the segments are organized according to the problem
they are relevant for. For example, all segments with information relevant to cardiac
dysfunction are presented together in one flow sheet.
3.2 Granularity of Medical Narratives

Medical narratives are often presented as one text body of – more or less – flu-ent prose. Yet, it is
easy to divide them into meaningful segments. the Maastricht prototype EMR system to present
‘medical history’ at three different levels of granularity – all oc-curring among existing EMR systems :

 undivided (level 1),

 divided into segments describing organ systems(level 2),
 and divided into segments containing the patient’s answers to distinct questions (level 3).

The above-mentioned level 1 was presented in combination with undivided progress notes, the
levels 2 and 3 were presented in combination with progress notes that were divided into problem
related segments.

3.3 Technical Specifications of the Prototype EMR System

The Maastricht prototype EMR system was developed in Visual Basic 3.0TM, under MS-Windows
3.11TM. Segment labels and the organization of segments were specified in a Btrieve 5.0TM
database in which also the patient data were stored. We used Btrieve because it is very fast and
flexible. Medical narratives were stored as free text. Advanced text-processing functions to facilitate
searching were not available.