Applied Bimatics - An Informatics & eHealth Blog

I am a clinician with a passion for informatics. This blog is about my eHealth journey exploring interoperability in Electronic Medical Records (EMR/EHR), Patient Safety, Pharmacovigilance, Data Analytics, Clinical Research and Bioinformatics in a clinical context. Comparing Canadian, Indian and Middle Eastern healthcare systems and services. Join our open facebook group here: https://www.facebook.com/groups/clinical.bioinformaticians/


Physician-patient encounter for HMIS & eHealth

A physician performs a routine checkup on a pa...
A physician performs a routine checkup on a patient at the medical clinic. (Photo credit: Wikipedia)
As physicians, the patient-encounter is a routine process that we hardly analyze in a scientific manner. But the physician-patient encounter is extremely important from the perspective of health management information systems. Though the workflow and thought-flow may vary based on the setting, individual and specialty, I have tried to summarize basic steps in a physician-patient encounter.

Initially there will be a rapport building phase for new patients which naturally will be unstructured. This is followed by history taking and clinical examination. A physician may take notes during this process, but the information on his notes generally will be semi-structured. This information is transcribed into the EMR in a fully structured form though free form text may be needed to capture certain elements.
Physician patient encounter

The basic steps in a physician-patient encounter 

The physician arrives at a list of probable diagnosis (differentials) following which the physician may go back to history taking and examination to find more clues for a definitive diagnosis. Clinical decision support systems (CDSS) may be useful during this phase. Physician requests  investigations and comes to a more specific diagnosis.

Management starts with a specific diagnosis in most cases. CDSS helps during this phase along with computerized physician order entry (CPOE) and ePrescription. When the patient comes for follow-up, these steps are repeated and the initial diagnosis is re-evaluated.

Labels: , , , , , ,



Post a Comment

All comments, questions and criticisms welcome. Relevant comments with hyperlinks will be accepted. Though this form is not CommentLuv enabled, interesting and useful comments will be acknowledged with DoFollow links in the body of the post. Irrelevant comments and spam will be deleted.

Links to this post:

Create a Link

<< Home

About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.

Address

Bell Raj Eapen
Hamilton, ON
Canada