Computer-based records in the clinic ( a )

Abstract

Conventional medical records provide a source of data for the purposes of clinical research which is limited both in its scope and in its accessibility. Special systems of data collection for specific clinical investigations usually involve duplication of recording by requiring the completion of special forms in addition to the usual case notes. A computer system which was designed to collect, process and display routine medical data relating to hypertensive patients in a clinically useful way, and to file them in a way that renders them accessible for research purposes, is outlined. The system has been in operation at three clinics for approximately 2 years. The way in which an attempt has been made to meet three design objectives is described. These objectives are: (1) that the structure of the set of data should allow an adequate description of a patient’s clinical condition as it changes with time; (2) that the method of representing the data should be appropriate to both clinical and research needs; and (3) that the method of data display for the clinical environment should provide benefits to counteract the inevitable burden of a more formal system of data recording.