Abstract
Research has shown that physicians find a medical expert system much more attractive if the system can provide in addition to diagnostic support some relief from the heavy burden of responsibility for daily record keeping required in hospital practice. This paper introduces a sophisticated interactive system for generating daily progress notes designed to function as an integral part of MEDAS (the Medical Emergency Decision Assistance System). MEDAS is a pattern-recognition expert system, using multi-membership Bayesian inference. At hospital admission, the MEDAS diagnosis module and severity module produce a problem list and assign a severity code to each problem. In many hospitals, physicians are expected to provide daily progress notes discussing the patient's condition with respect to each problem area. For each problem, they need to consider subjective and objective information, assessment and make a plan for handling the problem. The items to be considered depend on the specific problem: remembering these items is a huge memory load; writing it all down is very time-consuming. Our system presents the physician with a series of problem-specific menus, making data entry easy and rapid. Finally, it automatically generates the necessary output for the patient record.
We want to thank Dr. Daniel Woodard of Bionetics and Dr. Paul Buchanan of NASA for their advice and support.
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References
G.O. Barnett. The application of computer-based medical-record systems in ambulatory practice. N Engl J Med. 1984;310:1643–1650.
M. Ben-Bassat, R.W. Carlson, V.K. Puri, M.D. Davenport, J.A. Schriver, M.H. Weil. Pattern-based interactive diagnosis of multiple disorders: The MEDAS system. IEEE Transactions in Pattern Analysis and Machine Intelligence. 1980;148–160.
M.B. Bischoff, E.H. Shortliffe, A.C. Scott, R.W. Carlson, C.D. Jacobs. Integration of a computer-based consultant into the clinical setting. Proceedings of the Seventh Annual Symposium on Computer Applications in Medical Care, IEEE, 1983:149–152.
A.R. Feinstein. The problems of the “problem-oriented medical record.” Annals of Internal Medicine. 1973;78:751–762.
W.J. Fessel, E.E. Van Brunt. Assessing quality of care from the medical record. N Engl J Med. 1972;286:34–38.
N.N. Finer, A.J. Fraser. Neonatal data base and automated discharge summary using a personal computer and proprietary software. Pediatrics. 1985;76:(2) 269–273.
R.H. Fletcher. Auditing problem-oriented records and traditional records: a controlled comparison of speed, accuracy, and identification or errors in medical care. N Engl J Med.. 1974;290:829–833.
H.H. Friedman. Problem-Oriented Medical Diagnosis. Little Brown and Company, Boston, 1987.
W.E. Hammond, W.W. Stead, M.J. Straube, F.W. Jelovsek. Functional characteristics of a computerized medical record. Methods Inf Med. 1980; 19:157–162.
J.W. Hurst. Ten reasons why Lawrence Weed is right. N Engl J Med. 1971, 284:51–52.
I.M. Kuhn, G.W. Wiederhold. The evolution of ambulatory medical systems in the U.S. In: H.G. Heffernan, (ed.) Proceedings of the Fifth Annual Symposium on Computer Applications in Medical Care. IEEE, 1981:80–85.
C.J. McDonald, S.L. Hui, D.M. Smith. Reminders to physicians from an introspective computer medical record. Annals of Internal Medicine. 1984. 100:130–138.
M.J. Meldman, D. Harris, J.P. Robert, E.A. Johnson. A computer-assisted, goal-oriented psychiatric progress note system. Am J Psychiatry. 1977;134:38–41.
F. Naeymi-Rad. A feature dictionary for a multi-domain medical knowledge base. Proceedings of the Twelfth Annual Symposium on Computer Applications in Medical Care, IEEE, 1988:212–217.
M.S. Roberts, J.D. Zibrak, A. Siders. The development of an on-line, partially automated discharge summary and core clinical data-base in an existing hospital information system. Proccedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care. IEEE, 1989:649–653.
D.W. Simborg, Q.E. Whiting-O'Keefe. Summary time oriented record (STOR) — a progress report. Proceedings of the Fifth Annual Symposium on Computer Applications in Medical Care. IEEE, 1981:100–103.
R.P. Smith, G.B. Holzman. The application of a computer data base system to generation of hospital discharge summaries. Obstetrics and Gynecology. 1989;73:(5), 803–807.
W.W. Stead, W.E. Hammond, M.J. Straube. A chartless record — is it adequate? Proceedings of the Sixth Annual Symposium on Computer Applications in Medical Care. IEEE, 1982:89–94.
P.H. Stern, B.S. Rubin. Computerized discharge sumaries. Arch Phys Med Rehabil. 1979;60:25–29.
L.L. Weed. Medical Records, Medical Education, and Patient Care. The Problem-Oriented Record as a Basic Tool. Chicago, Year Book Medical Publishers, Inc., 1970.
Q.E. Whiting-O'Keefe, D.W. Simborg, W.V. Epstein, A.A. Warger. A computerized summary medical record system can provide more information than the standard medical record. JAMA. 1985;254:1185–1192.
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© 1991 Springer-Verlag Berlin Heidelberg
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Ma, HN.N., Evens, M., Trace, D.A., Naeymi-Rad, F. (1991). An interactive system for generating hospital progress notes. In: Sherwani, N.A., de Doncker, E., Kapenga, J.A. (eds) Computing in the 90's. Great Lakes CS 1989. Lecture Notes in Computer Science, vol 507. Springer, New York, NY. https://doi.org/10.1007/BFb0038518
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DOI: https://doi.org/10.1007/BFb0038518
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