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Develop a representation of clinical observations and actions and a method of processing free-text patient documents to facilitate applications such as quality assurance.

Articles about medical diagnostic decision support (MDDS) systems often begin with a disclaimer such as, "despite many years of research and millions of dollars of expenditures on medical diagnostic systems, none is in widespread use at the present time." While this statement remains true in the sense that no single diagnostic system is in widespread use, it is misleading with regard to the state of the art of these systems [...]

To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms.

A major obstacle to establishing a computer-stored medical record is the lack of "standards" that would permit government, care providers, insurance companies, and medical computer system developers to share patient data easily. In this position paper, the Board of Directors of the American Medical Informatics Association recommends specific approaches to standardization in the areas of patient, provider, and site of care identifiers; computerized health care message exchange; medical record content [...]

The International Classification of Functioning, Disability and Health (ICF) is the World Health Organization's standard for describing health and health-related states. Examples of how the ICF has been used in Electronic Health Records (EHRs) have not been systematically summarized and described yet.

The development of telemedicine and telecare has been changed all over the world the recent decades as practitioners and health care managers reached better understanding of the use of information and communication technologies to offer urgent and qualified medical services at a distance. Governments and health care providers have shown a large initial interest in the benefits of telemedicine services to reduce costs mostly for patient's transfer to tertiary hospitals [...]

Twenty-four hour ambulatory electrocardiograms ("Holter" monitors) are a key diagnostic test in cardiology. Commercial electronic medical record (EMR) tools have not been designed for pediatric Holter monitor reporting and paper-based methods are inefficient.

The emerging operational role of the "Chief Clinical Informatics Officer" (CCIO) remains heterogeneous with individuals deriving from a variety of clinical settings and backgrounds. The CCIO is defined in title, responsibility, and scope of practice by local organizations. The term encompasses the more commonly used Chief Medical Informatics Officer (CMIO) and Chief Nursing Informatics Officer (CNIO) as well as the rarely used Chief Pharmacy Informatics Officer (CPIO) and Chief Dental [...]