RESUMO
Intermountain Health Care has integrated the electronic medical record (EMR) with online information resources in order to create easy access to a knowledge base which practicing physicians can use at the point of care. When a user is reviewing problems/diagnosis, medications, or clinical laboratory test results, they can conveniently access a "pertinent paragraph" of reference literature that pertains to the clinical data in the EMR. Using terminology first coined by Cimino1, we call this application the "infobutton." We describe the architectural issues involved in linking our electronic medical record with a structured laboratory knowledge base. The application has been well received as noted by anecdotal comments made by physicians and usage of the application.
Assuntos
Técnicas de Laboratório Clínico , Armazenamento e Recuperação da Informação/métodos , Logical Observation Identifiers Names and Codes , Sistemas Computadorizados de Registros Médicos , Humanos , Hipermídia , Sistemas Automatizados de Assistência Junto ao Leito , PubMed , Obras Médicas de Referência , Integração de Sistemas , Vocabulário ControladoRESUMO
The burdens of increasing information overload, time constraints, and the high human and financial costs of medical error, mean that doctors cannot practice high quality evidence-based medicine without the aid of decision support systems at the point of care. The physician's role is to formulate a management plan based on clinical judgment, the patient's unique circumstances and preferences, and the best available evidence. Clineguide is a clinical knowledge system that will integrate into the workflow to improve patient outcomes, reduce variability of care, and promote efficiency in the health care process. This article discusses some of the issues surrounding the provision of rapid, accurate, and accessible information to health care professionals.