메뉴 건너뛰기




Volumn 15, Issue 1, 2008, Pages 54-64

An Electronic Health Record Based on Structured Narrative

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CLINICAL RESEARCH; ELECTRONIC MEDICAL RECORD; HUMAN; LANGUAGE; MEDICAL DOCUMENTATION; MEDICAL INFORMATION; QUALITY CONTROL; STANDARDIZATION; VALIDATION PROCESS;

EID: 36749031587     PISSN: 10675027     EISSN: None     Source Type: Journal    
DOI: 10.1197/jamia.M2131     Document Type: Article
Times cited : (108)

References (84)
  • 1
    • 0005418966 scopus 로고
    • Department of Health, Education and Welfare Report No.: DHEW (HRA) 76-3145
    • Barnett G.O. Computer-Stored Ambulatory Record (COSTAR) (1976), Department of Health, Education and Welfare Report No.: DHEW (HRA) 76-3145
    • (1976) Computer-Stored Ambulatory Record (COSTAR)
    • Barnett, G.O.1
  • 2
    • 0033025210 scopus 로고    scopus 로고
    • The Regenstrief Medical Record System: a quarter of a century experience
    • McDonald C., Overhage J., and Tierney W. The Regenstrief Medical Record System: a quarter of a century experience. Int J Med Inf 54 (1999) 225-253
    • (1999) Int J Med Inf , vol.54 , pp. 225-253
    • McDonald, C.1    Overhage, J.2    Tierney, W.3
  • 5
    • 0020957530 scopus 로고
    • A computer-based monitoring system for follow-up of elevated blood pressure
    • Barnett G.O., Winickoff R.N., Morgan M.M., and Zielstorff R.D. A computer-based monitoring system for follow-up of elevated blood pressure. Medical Care 21 4 (1983) 400-409
    • (1983) Medical Care , vol.21 , Issue.4 , pp. 400-409
    • Barnett, G.O.1    Winickoff, R.N.2    Morgan, M.M.3    Zielstorff, R.D.4
  • 6
    • 0343526800 scopus 로고    scopus 로고
    • Evaluation of the quality of information retrieval of clinical findings from a computerized patient database using a semantic terminological model
    • Brown P.J.B., and Sonksen P. Evaluation of the quality of information retrieval of clinical findings from a computerized patient database using a semantic terminological model. J Am Med Inform Assoc 7 4 (2000) 392-403
    • (2000) J Am Med Inform Assoc , vol.7 , Issue.4 , pp. 392-403
    • Brown, P.J.B.1    Sonksen, P.2
  • 7
    • 0031743292 scopus 로고    scopus 로고
    • A framework for comprehensive terminology systems in the United States: Development guidelines, criteria for selection, and public policy implications
    • ANSI Healthcare Informatics Standards Board Vocabulary Working Group and the Computer-based Patient Records Institute Working Group on Codes and Structures
    • Chute C.G., Cohn S.P., Campbell J.R., and ANSI Healthcare Informatics Standards Board Vocabulary Working Group and the Computer-based Patient Records Institute Working Group on Codes and Structures. A framework for comprehensive terminology systems in the United States: Development guidelines, criteria for selection, and public policy implications. J Am Med Inform Assoc 5 6 (1998) 503-510
    • (1998) J Am Med Inform Assoc , vol.5 , Issue.6 , pp. 503-510
    • Chute, C.G.1    Cohn, S.P.2    Campbell, J.R.3
  • 8
    • 0034069721 scopus 로고    scopus 로고
    • From data to knowledge through concept-oriented terminologies: experience with the Medical Entities Dictionary
    • Cimino J.J. From data to knowledge through concept-oriented terminologies: experience with the Medical Entities Dictionary. J Am Med Inform Assoc 7 3 (2000) 288-297
    • (2000) J Am Med Inform Assoc , vol.7 , Issue.3 , pp. 288-297
    • Cimino, J.J.1
  • 11
    • 0017181612 scopus 로고
    • Protocol-based computer reminders, the quality of care and the non-perfectibility of man
    • McDonald C.J. Protocol-based computer reminders, the quality of care and the non-perfectibility of man. New Engl J Med 295 (1976) 1351-1355
    • (1976) New Engl J Med , vol.295 , pp. 1351-1355
    • McDonald, C.J.1
  • 13
    • 0031209934 scopus 로고    scopus 로고
    • Clearing the way for physicians' use of clinical information systems
    • Anderson J.G. Clearing the way for physicians' use of clinical information systems. Comm ACM 40 8 (1997) 83-90
    • (1997) Comm ACM , vol.40 , Issue.8 , pp. 83-90
    • Anderson, J.G.1
  • 14
    • 0031781943 scopus 로고    scopus 로고
    • The state of computer-based patient record
    • Amatayakul M. The state of computer-based patient record. J AHIMA 69 (1998) 34-36
    • (1998) J AHIMA , vol.69 , pp. 34-36
    • Amatayakul, M.1
  • 15
    • 11144338247 scopus 로고    scopus 로고
    • Will the Wave Finally Break?. A Brief View of the Adoption of Electronic Medical Records in the United States
    • Berner E.S., Detmer D.E., and Simborg D. Will the Wave Finally Break?. A Brief View of the Adoption of Electronic Medical Records in the United States. JAMIA 12 (2005) 3-7
    • (2005) JAMIA , vol.12 , pp. 3-7
    • Berner, E.S.1    Detmer, D.E.2    Simborg, D.3
  • 16
    • 0036318237 scopus 로고    scopus 로고
    • If electronic records are so great, why aren't family physicians using them?
    • Loomis G.A., Ries J.S., Saywell R.M., and Thakker N.R. If electronic records are so great, why aren't family physicians using them?. J Family Practice 51 7 (2002) 636-641
    • (2002) J Family Practice , vol.51 , Issue.7 , pp. 636-641
    • Loomis, G.A.1    Ries, J.S.2    Saywell, R.M.3    Thakker, N.R.4
  • 17
    • 0031136464 scopus 로고    scopus 로고
    • The Barriers to Electronic Medical Record Systems and How to Overcome Them
    • McDonald C.J. The Barriers to Electronic Medical Record Systems and How to Overcome Them. J Am Med Inform Assoc 4 (1997) 213-221
    • (1997) J Am Med Inform Assoc , vol.4 , pp. 213-221
    • McDonald, C.J.1
  • 18
    • 0032517579 scopus 로고    scopus 로고
    • Opportunities for and challenges of computerization
    • Powsner S.M., Wyatt J.C., and Wright P. Opportunities for and challenges of computerization. Lancet 352 (1999) 1617-1622
    • (1999) Lancet , vol.352 , pp. 1617-1622
    • Powsner, S.M.1    Wyatt, J.C.2    Wright, P.3
  • 19
    • 0033125110 scopus 로고    scopus 로고
    • Physician data entry is the solution
    • Symes D.R. Physician data entry is the solution. Health Management Technology 20 (1999) 34
    • (1999) Health Management Technology , vol.20 , pp. 34
    • Symes, D.R.1
  • 20
    • 0036016997 scopus 로고    scopus 로고
    • The computerized patient record: balancing effort and benefit
    • Van Ginneken A.M. The computerized patient record: balancing effort and benefit. IJMI 65 (2002) 97-119
    • (2002) IJMI , vol.65 , pp. 97-119
    • Van Ginneken, A.M.1
  • 21
    • 24044539547 scopus 로고    scopus 로고
    • The impact of electronic health records on time efficiency of physicians and nurses: a systematic review
    • Poissant L., Pereira J., Tamblyn R., and Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc 12 5 (2005) 505-516
    • (2005) J Am Med Inform Assoc , vol.12 , Issue.5 , pp. 505-516
    • Poissant, L.1    Pereira, J.2    Tamblyn, R.3    Kawasumi, Y.4
  • 22
    • 0028488395 scopus 로고
    • Reducing barriers to physician data entry for computer-based patient records
    • Kaplan B. Reducing barriers to physician data entry for computer-based patient records. Topics in Health Information Management 15 1 (1994) 24-34
    • (1994) Topics in Health Information Management , vol.15 , Issue.1 , pp. 24-34
    • Kaplan, B.1
  • 23
    • 0032161272 scopus 로고    scopus 로고
    • Physician data entry: providing options is essential
    • Gilbert J.A. Physician data entry: providing options is essential. Health Data Management 6 9 (1998) 84-86
    • (1998) Health Data Management , vol.6 , Issue.9 , pp. 84-86
    • Gilbert, J.A.1
  • 24
    • 0027733436 scopus 로고
    • Real and imagined barriers to an electronic medical record
    • Rind D.M., and Safran C. Real and imagined barriers to an electronic medical record. AMIA (1993) 74-78
    • (1993) AMIA , pp. 74-78
    • Rind, D.M.1    Safran, C.2
  • 26
    • 0025823160 scopus 로고
    • Foundations for an electronic medical record
    • Rector A.L., Nowlan W.A., and Kay S. Foundations for an electronic medical record. Methods Inform Med 30 (1991) 179-186
    • (1991) Methods Inform Med , vol.30 , pp. 179-186
    • Rector, A.L.1    Nowlan, W.A.2    Kay, S.3
  • 29
    • 0029899339 scopus 로고    scopus 로고
    • The physician's flexible narrative
    • Van Ginneken A.M. The physician's flexible narrative. Methods Inform Med 35 2 (1996) 98-100
    • (1996) Methods Inform Med , vol.35 , Issue.2 , pp. 98-100
    • Van Ginneken, A.M.1
  • 30
    • 0028185704 scopus 로고
    • Evaluation of UltraSTAR: performance of a collaborative structured data entry system
    • Bell D.S., and Greenes R.A. Evaluation of UltraSTAR: performance of a collaborative structured data entry system. Proc Annu Symp Comp Appl Med Care (1994) 216-222
    • (1994) Proc Annu Symp Comp Appl Med Care , pp. 216-222
    • Bell, D.S.1    Greenes, R.A.2
  • 32
    • 0032941832 scopus 로고    scopus 로고
    • Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department
    • Marill K.A., Gauharou E.S., Nelson B.K., Peterson M.A., Curtis R.L., and Gonzalez M.R. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Annals Emerg Med 33 5 (1999) 500-509
    • (1999) Annals Emerg Med , vol.33 , Issue.5 , pp. 500-509
    • Marill, K.A.1    Gauharou, E.S.2    Nelson, B.K.3    Peterson, M.A.4    Curtis, R.L.5    Gonzalez, M.R.6
  • 33
    • 0028185824 scopus 로고
    • Impact of computerized physician order entry on physician time
    • Bates D.W., Boyle D.L., and Teich J.M. Impact of computerized physician order entry on physician time. AMIA (1994) 996
    • (1994) AMIA , pp. 996
    • Bates, D.W.1    Boyle, D.L.2    Teich, J.M.3
  • 34
    • 0027531457 scopus 로고
    • Physician inpatient order writing on microcomputer workstations-Effects on resource utilization
    • Tierney W.M., Miller M.E., Overhage J.M., and McDonald C.J. Physician inpatient order writing on microcomputer workstations-Effects on resource utilization. JAMA 269 3 (1993) 379-383
    • (1993) JAMA , vol.269 , Issue.3 , pp. 379-383
    • Tierney, W.M.1    Miller, M.E.2    Overhage, J.M.3    McDonald, C.J.4
  • 35
    • 0033258457 scopus 로고    scopus 로고
    • The transition to automated practitioner order entry in a teaching hospital: the VA Puget Sound experience
    • Payne T.H. The transition to automated practitioner order entry in a teaching hospital: the VA Puget Sound experience. AMIA 1-2 (1999) 589-593
    • (1999) AMIA , Issue.1-2 , pp. 589-593
    • Payne, T.H.1
  • 36
    • 0033987976 scopus 로고    scopus 로고
    • Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository
    • Stein H.D., Nadkarni P., Erdos J., and Miller P.L. Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository. JAMIA 7 (2000) 42-54
    • (2000) JAMIA , vol.7 , pp. 42-54
    • Stein, H.D.1    Nadkarni, P.2    Erdos, J.3    Miller, P.L.4
  • 38
    • 0028646205 scopus 로고
    • Data quality in computerized patient records-Analysis of a hematology biopsy report database
    • Hohnloser J.H., Fisher M.R., Koning A., and Emmerich B. Data quality in computerized patient records-Analysis of a hematology biopsy report database. Clin Monit Comput 11 4 (1994) 233-240
    • (1994) Clin Monit Comput , vol.11 , Issue.4 , pp. 233-240
    • Hohnloser, J.H.1    Fisher, M.R.2    Koning, A.3    Emmerich, B.4
  • 39
    • 0000722330 scopus 로고
    • Rhetoric as skill in a medical setting
    • Bloor N., and Taraborrelli P. (Eds), Avebury, Aldershot
    • Atkinson P. Rhetoric as skill in a medical setting. In: Bloor N., and Taraborrelli P. (Eds). Qualitative studies in health medicine (1994), Avebury, Aldershot
    • (1994) Qualitative studies in health medicine
    • Atkinson, P.1
  • 43
    • 0032723060 scopus 로고    scopus 로고
    • Preventable inpatient time: adequacy of electronic patient information systems
    • Katz D.L., Mazhari R., Kalus R., and Nawaz H. Preventable inpatient time: adequacy of electronic patient information systems. Am J Pub Health 89 12 (1999) 1885-1889
    • (1999) Am J Pub Health , vol.89 , Issue.12 , pp. 1885-1889
    • Katz, D.L.1    Mazhari, R.2    Kalus, R.3    Nawaz, H.4
  • 44
    • 0033987976 scopus 로고    scopus 로고
    • Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository
    • Stein H.D., Nadkarni P., Erdos J., and Miller P.L. Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository. Journal of the American Medical Informatics Association 7 1 (2000) 42-54
    • (2000) Journal of the American Medical Informatics Association , vol.7 , Issue.1 , pp. 42-54
    • Stein, H.D.1    Nadkarni, P.2    Erdos, J.3    Miller, P.L.4
  • 45
    • 0032723060 scopus 로고    scopus 로고
    • Preventable inpatient time: adequacy of electronic patient information systems
    • Katz D.L., Mazhari R., Kalus R., and Nawaz H. Preventable inpatient time: adequacy of electronic patient information systems. American Journal of Public Health 89 12 (1999) 1885-1889
    • (1999) American Journal of Public Health , vol.89 , Issue.12 , pp. 1885-1889
    • Katz, D.L.1    Mazhari, R.2    Kalus, R.3    Nawaz, H.4
  • 46
    • 0018771229 scopus 로고
    • Costs of unnecessary tests
    • Sandler G. Costs of unnecessary tests. British Medical Journal 2 6181 (1979) 21-24
    • (1979) British Medical Journal , vol.2 , Issue.6181 , pp. 21-24
    • Sandler, G.1
  • 50
    • 0026076154 scopus 로고
    • The quality of gastroenterological reports based on free text dictation: an evaluation in endoscopy and ultrasonography
    • Kuhn K., Swobodnik W., Johannes R.S., Zemmler T., Stange E.F., Ditschuneit H., and Classen M. The quality of gastroenterological reports based on free text dictation: an evaluation in endoscopy and ultrasonography. Endoscopy 23 5 (1991) 262-264
    • (1991) Endoscopy , vol.23 , Issue.5 , pp. 262-264
    • Kuhn, K.1    Swobodnik, W.2    Johannes, R.S.3    Zemmler, T.4    Stange, E.F.5    Ditschuneit, H.6    Classen, M.7
  • 52
    • 0032695954 scopus 로고    scopus 로고
    • Standardized medical record: a new outpatient osteopathic SOAP note form: validation of a standardized office form against physician's progress notes
    • Sleszynski S.L., Glonek T., and Kuchera W.A. Standardized medical record: a new outpatient osteopathic SOAP note form: validation of a standardized office form against physician's progress notes. J Am Osteopath Assoc 99 10 (1999) 516-529
    • (1999) J Am Osteopath Assoc , vol.99 , Issue.10 , pp. 516-529
    • Sleszynski, S.L.1    Glonek, T.2    Kuchera, W.A.3
  • 54
    • 0027526398 scopus 로고
    • Improving the quality and ease of tracking invasive procedures
    • Van Ruiswyk J., and Erdmann M. Improving the quality and ease of tracking invasive procedures. Med Ed 27 1 (1993) 86-90
    • (1993) Med Ed , vol.27 , Issue.1 , pp. 86-90
    • Van Ruiswyk, J.1    Erdmann, M.2
  • 56
    • 0032765543 scopus 로고    scopus 로고
    • The application of a computerized problem-oriented medical record system and its impact on patient care
    • Ho L.M., McGhee S.M., Hedley A.J., and Leong J.C. The application of a computerized problem-oriented medical record system and its impact on patient care. Int J Med Inform 55 1 (1999) 47-59
    • (1999) Int J Med Inform , vol.55 , Issue.1 , pp. 47-59
    • Ho, L.M.1    McGhee, S.M.2    Hedley, A.J.3    Leong, J.C.4
  • 57
    • 0031603672 scopus 로고    scopus 로고
    • Standardized or narrative discharge summaries. Which do family physicians prefer?
    • van Walraven C., Duke S.M., Weinberg A.L., and Wells P.S. Standardized or narrative discharge summaries. Which do family physicians prefer?. Can Fam Phys 44 (1998) 62-69
    • (1998) Can Fam Phys , vol.44 , pp. 62-69
    • van Walraven, C.1    Duke, S.M.2    Weinberg, A.L.3    Wells, P.S.4
  • 58
    • 0033537501 scopus 로고    scopus 로고
    • Dictated versus database-generated discharge summaries: a randomized clinical trial
    • van Walraven C., Laupacis A., Seth R., and Wells G. Dictated versus database-generated discharge summaries: a randomized clinical trial. CMAJ 160 3 (1999) 319-326
    • (1999) CMAJ , vol.160 , Issue.3 , pp. 319-326
    • van Walraven, C.1    Laupacis, A.2    Seth, R.3    Wells, G.4
  • 61
    • 0031136464 scopus 로고    scopus 로고
    • The barriers to electronic medical records and how to overcome them
    • McDonald C.J. The barriers to electronic medical records and how to overcome them. JAMIA 4 (1997) 213-221
    • (1997) JAMIA , vol.4 , pp. 213-221
    • McDonald, C.J.1
  • 62
    • 0032161272 scopus 로고    scopus 로고
    • Physician data entry: providing options is essential
    • Gilbert J.A. Physician data entry: providing options is essential. Health Data Management 6 (1998) 84-86
    • (1998) Health Data Management , vol.6 , pp. 84-86
    • Gilbert, J.A.1
  • 65
    • 0347210458 scopus 로고    scopus 로고
    • Puya: a method of attracting attention to relevant physical findings
    • de Estrada W.D., Murphy S., and Barnett G.O. Puya: a method of attracting attention to relevant physical findings. Proc AMIA Annu Fall Symp (1997) 509-513
    • (1997) Proc AMIA Annu Fall Symp , pp. 509-513
    • de Estrada, W.D.1    Murphy, S.2    Barnett, G.O.3
  • 66
    • 36749099299 scopus 로고    scopus 로고
    • Proc Intern Conf Found Data Org, Kobe, Japan, November
    • Suciu D. Proc Intern Conf Found Data Org, Kobe, Japan, November. Semistructured data and xml (1998)
    • (1998) Semistructured data and xml
    • Suciu, D.1
  • 69
    • 0033257575 scopus 로고    scopus 로고
    • XML and its impact on content and structure in electronic health care documents
    • Sokolowski R., and Dudeck J. XML and its impact on content and structure in electronic health care documents. Proc AMIA Annu Symp (1999) 147-151
    • (1999) Proc AMIA Annu Symp , pp. 147-151
    • Sokolowski, R.1    Dudeck, J.2
  • 71
    • 0642369735 scopus 로고    scopus 로고
    • The continuity of care record. Organizations unite to create a portable, electronic record for use at transfer points in patients' care
    • Tessier C., and Waegemann C.P. The continuity of care record. Organizations unite to create a portable, electronic record for use at transfer points in patients' care. Healthc Inform 20 10 (2003) 54-56
    • (2003) Healthc Inform , vol.20 , Issue.10 , pp. 54-56
    • Tessier, C.1    Waegemann, C.P.2
  • 72
    • 0033257739 scopus 로고    scopus 로고
    • Combining dictionary techniques with extensible markup language (XML)-requirements to a new approach towards flexible and standardized documentation
    • Altmann U., Tafazzoli A.G., Noelle G., Huybrechts T., Schweiger R., Wachter W., and Dudeck J.W. Combining dictionary techniques with extensible markup language (XML)-requirements to a new approach towards flexible and standardized documentation. Proc AMIA Annu Symp (1999) 12-16
    • (1999) Proc AMIA Annu Symp , pp. 12-16
    • Altmann, U.1    Tafazzoli, A.G.2    Noelle, G.3    Huybrechts, T.4    Schweiger, R.5    Wachter, W.6    Dudeck, J.W.7
  • 75
    • 0033257806 scopus 로고    scopus 로고
    • WebCIS: large scale deployment of a Web-based clinical information system
    • Hripcsak G., Cimino J.J., and Sengupta S. WebCIS: large scale deployment of a Web-based clinical information system. Proc AMIA Annu Symp (1999) 804-808
    • (1999) Proc AMIA Annu Symp , pp. 804-808
    • Hripcsak, G.1    Cimino, J.J.2    Sengupta, S.3
  • 77
    • 34748864710 scopus 로고    scopus 로고
    • Heuristic evaluation of eNote: an electronic notes system
    • Bright T.J., Bakken S., and Johnson S.B. Heuristic evaluation of eNote: an electronic notes system. AMIA Annu Symp Proc (2006) 864
    • (2006) AMIA Annu Symp Proc , pp. 864
    • Bright, T.J.1    Bakken, S.2    Johnson, S.B.3
  • 80
    • 0034069721 scopus 로고    scopus 로고
    • From data to knowledge through concept-oriented terminologies: experience with the Medical Entities Dictionary
    • Cimino J.J. From data to knowledge through concept-oriented terminologies: experience with the Medical Entities Dictionary. J Am Med Inform Assoc 7 3 (2000) 288-297
    • (2000) J Am Med Inform Assoc , vol.7 , Issue.3 , pp. 288-297
    • Cimino, J.J.1
  • 81
    • 36749056698 scopus 로고    scopus 로고
    • Web Ontology Language (OWL). Available at: www.w3.org/TR/owl-features/. Accessed.
  • 82
    • 4544280638 scopus 로고    scopus 로고
    • Automated encoding of clinical documents based on natural language processing
    • Friedman C., Shagina L., Lussier Y., and Hripcsak G. Automated encoding of clinical documents based on natural language processing. J Am Med Inform Assoc 11 5 (2004) 392-402
    • (2004) J Am Med Inform Assoc , vol.11 , Issue.5 , pp. 392-402
    • Friedman, C.1    Shagina, L.2    Lussier, Y.3    Hripcsak, G.4
  • 83
    • 36749068808 scopus 로고    scopus 로고
    • Software AG. Available at: www.softwareag.com. Accessed.
  • 84
    • 0003525850 scopus 로고    scopus 로고
    • Committee on Quality of Health Care in America, Institute of Medicine, National Academy of Sciences, Washington, D.C 164
    • Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century (2001), Institute of Medicine, National Academy of Sciences, Washington, D.C 164
    • (2001) Crossing the Quality Chasm: A New Health System for the 21st Century


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.