aDepartment of Medical Information Science, Osaka University Hospital
bNEC Corporation
cOsaka National Hospital
Abstract:Electronic patient record is expected to have edit, data analysis, and
decision supporting functions. To realize these functions, the entered data should be structured. We made the template based data entry system with some devices. We defined a template for each describing unit, i.e.,
symptom, physical finding and examination report. Template is composed of several describing elements (a pair of property and value), which form tree structure in general. When a template is selected, the top layer of the elements are displayed at once allowing data entry. When the data qualified by other elements is entered then system presents the second layer about this data at once. This enable user to skip entering some unnecessary items. User can constitute a form by combining some templates frequently used in a situation. Furthermore, at the second patient visit, the system can present the templates used in the former patient visit to check the different point. These templates and forms can be made easily by editing the master data using template master maintenance program. The entered patient data are presented in progress note and flow sheet. In progress note, the entered data are translated into natural language. In the flow sheet, representative data of each template are present in the cell of the matrix whose line indicates the describing unit and column indicates date.
If the cell is clicked, then the details are presented. Using this system,
we made templates and forms for cardiovascular field and entered the data about a actual patient with angina pectoris. The time taken by inputting data is shorter than that by handwriting and the content is enough for a patient record. This system is practical for structured data entry in electrical patient record.
Keywords: Erectronic patient record; Template; Progress note; Flow sheet
1) Edit function: Entered data should be edited from the user's view point to undestand the patient history quickly.
2) Data Analysis function: Entered data are stored into database and should be analyzed for various purposes [3].
3) Decision supporting function: In order to criticize the doctor's action by the system, knowledge base should be retrieved automatically by the entered data [2,4].
To realize the structured data entry we developed a template base data entry system, in which user entered the data according to the form presented by the system [5]. The template base data entry tend to limit what user intend to enter in general. To overcome this demerits, our system takes some devices. This paper describes the data entry system developed to realizing structured data entry in electronic patient record and its relevant systems [6].
We made the data entry form for each describing unit. We call this entry form as "template". A template composed of some pairs of item presenting part and data entry part. There are two types of data entry method, one is free text data entry and another is data entry by selecting options. In selecting options, if sole data must be selected, radiobutton or combobox are available, if pleural option or combobox are available, if pleural options allow to be selected, checkbuttun or list box are available. ure, the system initially presents top layer elements of the structure at once and allow user to enter data, after inputting the data which qualified by some elements, it presents the second layer elements about the data at once. For example, after selecting the template about heart sound, the system presents the items in this template, i.e. "first heart sound", "second heart sound", "other heart sound" and "heart murmur". If "holosystolic murmur" is entered in "heart murmur", then the system presents the items as to "location of the murmur", "loud", "pitch" and "nature". If two kinds of murmurs are entered, the system presents two set of these items for each murmur (Fig. 1).
It is not convenient if user have to select several templates individually during consultation of each patient especially in entering physical findings. In this system, user can constitute a form by combining some templates frequently used in a situation, so that user can enter most of the data by using few forms. In entering a symptom, user have to select the suitable one from many templates. In this system, group can be defined which includes some templates or child groups, so that user can search the template according to the hierarchy of the groups.
At the second time visit, doctor checks what changes in patient state comparing to those observed in the former consultation. This system have a special form for succession in which the templates used in former consultation. In some data entry field in each template, the former data are presented, and user checks them whether they change or not. If none of the element of a template changes, then user enter "no change". If user does not check as to the data of a template (this case occurs about physical finding), or the subject of a template has been diminished (this case occurs about symptom), then user enter "no check" or "diminish" respectively.
There are two system to displaying the entered data. One is progress note, in which data are presented by natural language like a paper based medical record (Fig. 2). The structured data entered into the system are translated into natural language according to some simple rules. The other displaying system is flow sheet. Flow sheet is a matrix whose line indicates describing unit, and the column indicate date, and the cell present the representative data of the corresponding describing unit and date. By clicking the cell, the details of the data are shown, and by clicking date, the corresponding progress note is shown (Fig. 3). When the subject name is clicked, the data corresponding to the describing unit are shown successively.
Because data and program are completely separated in this data entry system, template or form can be constitute by editing the master data. There are four types of master data; i.e., form master, template master, property master, value master. To support user to edit these master data, we prepared the master data maintenance program. Using this system, users can easily constitute a template or a form as what they desire (Fig. 4).
The patient data entered by this system stored into 4 types of databases.
1) DB for used template
2) DB for entered data
3) DB for flow sheet
4) DB for progressnote
Former two databases are to constitute templates used in the former consultation. For this purpose, full data are necessary, but these data need not be kept for a long time. The latter two databases are to present the entered data in progress note or in flow sheet. Data structure of these databases are simple, but they have to be kept for a long time. The structured data are stored in the DB for flow sheet. Thus it can also be used for data analysis. The basic structure of this database except for patient ID, date, template ID is as follow.
1, 0, I01-V01
2, 1, I02-V09
3, 2, I03-V12
4, 0, I01-V02
5, 4, I02-V09
6, 5, I03-V12
Those are element No in template, parent element No, and property-value respectively. Using the attribute of parent element No, these data can be reconstituted in tree structure form.
We made the templates about chest pain, palpitation, and dyspnea as symptom and heart rate, blood pressure, heart sound, breath sound, liver, edema as physical findings. We entered the data about a actual patient with heart disease using these templates. The basic information about the chest pain of this patient could be entered by this system, and it took 35 sec, which was less than the time taken by handwriting (95 sec). Thus input using this system was not slower than by handwriting. However, the information heard from a patient was arranged to input them using a template, thus some comment by free text was need for complete record. As for record of physical findings, it was easy to input data and the contents were enough as patient medical record. It took 40 sec to enter these data, which was also less than that by handwriting (50 sec). Thus as regarding physical findings, user could record more quickly and completely by using template than by handwriting.
The record at the second patient visit, it took 45 sec to record by using the form for succession in this system, which was as long as that by handwriting. The record data were transferred to natural language in progress note, which were quite natural. The data presentation by flow sheet was helpful to comprehend the history of the patient. This presentation is expected to be more effective in patients with long history.
In this system, templates are made individually for each describing unit, and forms can be constituted easily by combining these templates. By taking this strategy, it is easy to cope with a variety of subject in record among doctors. For example, record about physical findings usually made by a doctors is varied according to his/her specialty, however, some subjects are commonly recorded by some doctors. In this system, each doctor can constitute a form for his own by combining templates, most of which were defined commonly in the society, resulting the entered data could be standardized in the society. Record in detail is not necessarily required in medical record. In some cases abridged data can be allowed. To cope with both of these situations, the system present the items broadly so that user can chose the items to input. However, it is troublesome if all items included in the template are presented at once when the template is selected. Thus our system presents the first layer of the tree structure of the items at first. If the data which should be qualified by some other elements is inputted, then the system presents the second layer of the structure about the data. The following step is as the same way. This dynamic control of template makes user feel to enter data freely and efficiently.
The view point of patient is different between in the first patient visit and in the subsequent visit. Although in the first patient visit, doctors collect information helpful for diagnosis, in the second visit they check the differences from those observed in the former visit. We support the data entry in the subsequent visit by succeeding the template used in the former visit. Using this system, user can not only enter data easily but also they can enter the information about changes in the patient state. This information is important for medical record.
However, template is convenient for data entry, it is not suitable for data presentation, because it occupy the large area in the screen. Thus we translate the structured data into natural language using simple rules set in the master. This help user to see the entered data easily. However, presentation on screen is more difficult to comprehend the patient history than the present paper base patient record if the patient history is long. To support users to comprehend the patient history as a whole, we prepared the flow sheet presentation. In flow sheet, whose line indicate describing unit and column indicate date, the representative data are shown in the cell. In this way, more than 8 days record can be summarized in one screen, thus user can easily comprehend the patient history as a whole. The describing unit can be related to problems the patient has. Doctor can restrict the items shown in the flow sheet by the problem he/she is concerned. Thus user can see the record from his point of view.
Furthermore, the detail data can be shown by clicking the cell, date, or item, thus all kind of data can be seen from the flow sheet. This kind of data presentation is unique and impossible in paper based patient record, thus is expected to be effective to comprehend the patient history easily.
The effectiveness of the template base electronic patient record depend on the workmanship of the templates. In order to constitute a good template, trial and error process is inevitable. In our system, any templates can be constituted only by entering the master data. Furthermore, we prepared the maintenance program for the template master, which support user to constitute templates more easily.
Using this system, the entered data are structured, thus the following function can be realized. First is edit function. The flow sheet presentation is one of the example, in which the presenting data can be selected by the problem. We are going to make the more elaborate presentation; i.e., problem oriented display in which each element is linked with each problem thus the system can present the relevant information to the problem user selected, for example the bases of the problem, plan for the problem, and so on. Second is the data analysis function, which is possible using the database. In this database, each record has attributes of item, value, and the relation with other record. Although the structure of template is various, the structure of the entered data in the database is simple and unified, thus complicated analysis of the data for the clinical study may be possible. Third is the decision supporting function. In the next step, we will combine decision supporting system in which the knowledge base are retrieved automatically by the entered data, so that doctor's actions are criticized by the system.
[2] Linnarsson R.:"Decision support for drug prescription integrated with computer-based patient records in primary care", Med.Inf 1993:18(2) pp131-142.
[3] Moorman PW, Van Ginneken AM, Van Del Lei J, and Van Bemmel JH. A model for structured data entry based on explicit descriptional knowledge. Methods Inf. Med. 1994:33 pp454-63.
[4] Nelson BD, Gardner RM, Hedrick G, and Gould P. Computerized decision support for concurrent utilization review using the HELP system. JAMIA 1994:1 pp339-352.
[5] Yamazaki S, Satomura Y, Suzuki T, Arai K, Honda M, and Takabayashi K. The concept of ""Template" assisted electronic medical record". Proc. Medinfo 95 1995: pp249-252.
[6] Matsumura Y, Takeda H, Okada T, Kuwata S, Nakazawa H, Hazumi N, and Inoue M. Method of structured Data Entry in Electronic Patient Record. Jap. J. Med. Inform 1997:17(3 Suppl) pp193-201.
Osaka University Hospital, 2-15 Yamada-oka, Suita, Osaka, 565 Japan.
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matumura@hp-info.med.osaka-u.ac.jp