Health Information Management: Integrating Information Technology ...

6 INTRODUCTION
literature is replete with discussions about whether an Electronic Medical Record
should not rather be called an Electronic Patient Record (emphasizing the central
role of the patient) or, rather, an Electronic Health Record (emphasizing the fact
that there is much more than just ‘medical’ or ‘disease related’ information in a
record). For others, a Medical Record is something essentially different from a
Health Record—the former being limited to physician’s notes and physicianoriented
information; the latter being the all-encompassing record on the ‘whole
patient’.
This book does not want to take a stake in such definition quarrels. Yet it is
important to realize that they exist, and that what is precisely meant at any given
time by a label such as ‘medical record’ is not self-evident. Often, terminology
oversells the underlying product: at best, the intelligence of ‘intelligent systems’
lies in their design and their use; at worst, ‘intelligent systems’ are an affront to
any intelligent person working with it. Similarly, a ‘data warehouse’ and ‘data
mining’ allude to highly lucrative activities and the ‘golden nuggets’ of
information that the organization has at its fingertips. ‘Databases’ and ‘doing
searches’ sound much less interesting, although that is basically what lies
beneath the rhetoric.
We will use the term ‘Information Technology’ (IT) throughout this book,
although some prefer the term ‘Information and Communication Technology’
(ICT). We intend no definition quarrel here either, although we do not focus on
telecom applications, for example.
As said, we will here use the term ‘Patient Care Information Systems’ (PCIS)
to address those systems that are used primarily by health care professionals and
patients, and that are primarily oriented to the support of their tasks. Among others,
the following systems that we will encounter in this book belong to this category
(for more technical details, please consult a leading Medical Informatics
handbook such as (Coiera, 2003; van Bemmel, 1997)).
Table 1.1 Some examples of patient care information systems
Electronic Patient Record (EPR)
Patient Information System(PIS)
The EPR is primarily a database containing
patients’ information. Through its retrieval
functions it should allow the health professional
easy access to stored patient information.
Through its input functions, it should allow
adequate and easy storage of patient information.
In this book, the terms ‘patient record’ and
‘medical record’ are used interchangeably.
A Patient Information System is a system that is
primarily oriented towards a patient, allowing
electronic access to his/her record and/or to
(individualized) patient education material. It
could also contain modes of electronic
communication with health care professionals
and/or decision support modules.