Bridging the gap between medical narratives and structured data in the computerized patient record

Abstract

Care documentation is a central activity of care delivery and a mandatory step to the development of predictive and supportive care informatics in a collaborative paradigm. Beside its importance for classical data processing in healthcare such as reimbursement claims, scientific research or teaching, care documentation must also fit within the daily work of healthcare providers without intrusion and remain a precise and life biography of the patient. In this view, human-machine interfaces and philosophy behind data acquisition and restitution interfaces are of major importance. There have always been some antagonisms between narratives and structured data entry, both having advantages and disadvantages, supporters and detractors. In real practice, most documents used in clinical settings are made both of typed or structured data and narratives or free texts. In order to try to have a common source for all these information, we developed a unified representation, acquisition and storage system for medical information. To use this system in our computerized patient record, we use a middleware based on HTTP and XML that permits standardized exchanges between applications and data repositories. This paper is devoted to the description of some part of our system as well as its real implementation in a CPR working in the five Geneva University Hospitals.