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Re: OB Electronic Medical RecordFrom: David A. Nagey, M.D., Ph.D., FACOG (dnagey@welchlink.welch.jhu.edu)Mon Jul 22 22:29:06 1996
ggk wrote: > > David A. Nagey, M.D., Ph.D., FACOG wrote: > > > > If you are interested in getting the latest version of thoughts on what > > ought to go into an electronic obstetric medical record AND if you are > > willing to read it and comment back to me AND if you haven't already > > gotten a copy (dated today), please email me PRIVATELY and I'll forward > > you a copy. > > > > Thanks > > > > David > > David Nagey, The Johns Hopkins University School of Medicine > > dnagey@welchlink.welch.jhu.edu > > Please send a copy to me. > Thanks. > > ggk Thank you for your continued efforts on the part of developing standards for electronic obstetric medical records. Your responses to a "strawman" sent out in May have been compiled and are below in the form of a modified original. Please mark-up this penultimate version and reply to me no later than the end of this month that I may take the final version to the committee meeting in Boston 8/2/96. Thank you again for your interest, thoughts and expertise. Please note that my address, telephone and FAX information has all changed. Please forgive the lack of formatting, but this had to be sent as text. my information: David A. Nagey, M.D., Ph.D., FACOG 600 N. Wolfe Street, Houck 204 Baltimore, MD 21287-1204 (410) 614-5144 or (888) 800-8150 (410) 849-2742 or (410) 614-8305 FAX dnagey@welchlink.welch.jhu.edu The Modified Strawman: Electronic Medical Records relating to reproductive health should: I. be secure A. data entry should require at least one level of password 1. consideration should be given to several security modes so that locations with less physical security (e.g. dial-up's) have more software security 2. selectable fields should be able to require different security levels than general access (e.g. medical data beyond diagnoses and procedures not accessible to financial users) B. each entry or modification should be marked with the date and time of the entry and the identification and location of the person making the entry C. it should be impossible for any user to be logged on more than once without system administrator approval and it should be possible to allow certain users to be logged on only from certain sites D. any deleted or modified data should never be erased, rather should be retrievable by appropriate users E. any inspection of data should generate a log entry including the date and time, and the identity and location of the browser F. it should be possible to set automatic alarms to the system administrator, with the potential to call or page that person 1. when the system is out of service for any reason 2. when repeated unsuccessful entry attempts are made 3. when selected users inspect records for patients not admitted II. be robust A. permit modification of the record form itself 1. appropriately filter old fields into new fields 2. place unknown data markers into new fields when no old data present B. permit linkage with other records (e.g. prior admissions, old laboratory data), utilizing a variety of keys including but not limited to the social security number, the medical record number or some variation on the name of the patient and her mother and the patient's date of birth C. always inform the user of the existence of other records concerning this patient and if the user's security level is appropriate, permit access D. permit creation of a fetal medical record in case there is fetal information that should not be automatically included in the mother's medical record (e.g. Huntington's chorea gene) III. be intuitive with respect to entering and retrieving information A. tutorials available from every workstation 1. system manager can opt to bar access for any user not successfully completing a specified portion of the tutorial 2. tutorial can be stopped at any point and later resumed B. context-specific help screen available for all fields C. retrieval of data can be accomplished by marking fields on similar screens to the entry screens IV. be entered by the provider at the time and point of care A. patients can enter data for later review by the provider B. use of hand-held devices for data entry and retrieval is encouraged as the technology becomes sufficiently robust V. avoid free text as much as possible A. diagnoses, findings, and procedures should be choices on a pick-list 1. new entries should be possible, but would then require subsequent arbitration by the system manager for possible inclusion in the pick-list 2. all entries should be from a defined medical language dictionary B. seldom used items from the pick-lists should be periodically reviewed for potential deletion or inclusion in a "seldom-used" pick-list VI. required fields should be selectable by the system manager, but be kept to the minimum number necessary for the record to fulfill its purpose VII. utilize "no response" as the default entry A. positive responses should be high-lighted B. negative responses should be present in some fashion on standard data output C. it should be easy to account for no response entries by provider so that those providing less than optimal information can receive additional training VIII. never require the same information to be entered more than once IX. permit automatic provider notification if certain conditions are met (e.g. RhIg suggested for consideration in Rh negative patients at 28 weeks, with bleeding and after procedures) A. provide for easy indication that suggestions were followed B. provide for simple indication why suggestions were not followed C. include help screens to explain suggestions X. permit facilitated quality assurance A. selectable outcomes trigger reports to selected users B. permit easy comparison of data across and between record systems by utilizing defined field sizes and characteristics and storing data in flat files without embedded control characters XI. permit access to selectable resource documents as an easy option at any time without interruption of data entry/retrieval XII. facilitate completion of other reports A. birth certificates B. resident activity forms C. letters to referring physicians D. prescription writing and drug information sheets E. operative notes and discharge summaries XIII. minimize the time required for completion and the space required for storage A. minimize the storage of blank fields B. do not require "tab'ing through" fields - allow point-and-click'ing to get to a field C. utilize a hierarchical screen structure so that certain screens are displayed only when there is likely data to be entered there XIV. facilitate inclusion of data from other sources A. laboratory B. other specialties C. other admissions within this specialty D. review and acceptance or rejection of data from other sources should be noted including the usual log entries XV. permit record sharing with other vendor systems complying with these standards A. allow importation and exportation of data as free text B. utilize standardized formatting of screens and printouts so that data never has to be in any form other than flat ASCII files
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