Managing the life cycle of electronic clinical documents.

Journal of the American Medical Informatics Association : JAMIA
Thomas H Payne, Gail Graham

Abstract

To develop a model of the life cycle of clinical documents from inception to use in a person's medical record, including workflow requirements from clinical practice, local policy, and regulation. We propose a model for the life cycle of clinical documents as a framework for research on documentation within electronic medical record (EMR) systems. Our proposed model includes three axes: the stages of the document, the roles of those involved with the document, and the actions those involved may take on the document at each stage. The model includes the rules to describe who (in what role) can perform what actions on the document, and at what stages they can perform them. Rules are derived from needs of clinicians, and requirements of hospital bylaws and regulators. Our model encompasses current practices for paper medical records and workflow in some EMR systems. Commercial EMR systems include methods for implementing document workflow rules. Workflow rules that are part of this model mirror functionality in the Department of Veterans Affairs (VA) EMR system where the Authorization/ Subscription Utility permits document life cycle rules to be written in English-like fashion. Creating a model of the life cycle of clinical docume...Continue Reading

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Citations

Sep 10, 2009·Clinical Trials : Journal of the Society for Clinical Trials·Jack W LondonJ Bruce Smith
Oct 28, 2008·Journal of the American Medical Informatics Association : JAMIA·Shane R RetiCharles Safran
Sep 12, 2007·Cardiovascular Engineering·Maxwell Lewis Neal, James B Bassingthwaighte

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