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: , , , , , ,


commentAdd Your Comments/Suggestions/Criticisms! | View Comments | Links to this post

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