An initial operational problem oriented medical record system

Abstract

The ultimate role of the computer in the delivery of health services has yet to be defined. There may be profound implications in terms of quality of medical care, efficiency, economics of care, and medical research. Final judgments as to advisability and economic feasibility await the implementation of prototype total medical information systems and further technical developments directed toward lowering the high cost of currently developing systems. Development of less expensive hardware and real-time application of the present hardware and software must go on in parallel. We have been involved in the latter, and an experimental time-shared medical information system has been developed for storing and retrieving the total medical record, including both the narrative and the numeric data. This development has integrated the Problem Oriented Medical Record, a means of organizing medical data around a patient's problems, with a touch sensitive cathode ray tube terminal that allows structured input (with additional keyboard entry capability) by directly interfaced medical users (in particular the physician and the nurse).