Modeling the Clinical Observation Space of Electronic Medical Record in Primary Care

摘要

We present a new model for structuring clinical data in primary care, denoted by the observation space. This model is intended to be used within Electronic Medical Record (EMR), and is designed to meet the requirements of clinical contexts and nuances that characterize primary care practices. While these contexts are generally captured with free-text descriptions, structuring them makes the use of EMR very attractive, since it opens many possibilities such as clinical data exchange and the design of Clinical Decision Support Systems. In partnership with practitioners, the results presented in this paper are being used to build clinical patterns.