Though not yet in widespread use, there is no doubt that the computerized medical record is the inevitable future of medical recordkeeping. The many advantages of a computerized (or "electronic") medical record have been discussed and demonstrated in great detail elsewhere. There are numerous commercially available "electronic medical records" (EMR) currently on the market; there is not yet one overwhelming standard. Interestingly, it also appears that there is not yet a usable, commercially available problem oriented computerized record.
The philosophy of problem oriented medical recordkeeping was introduced by Lawrence Weed, MD in the days of paper records, and was widely adopted. Migration of this concept to the electronic world has been slow, though Dr. Weed did produce a DOS prototype that is still in use today. Efforts to develop a modern, commercially viable computerized problem oriented patient record (CPOPR) (Windows or Mac compatible) have been stymied by technical and cultural issues.
A blueprint describing the structure and function of a CPOPR has been published. Technically inclined individuals might enjoy the white paper (a .pdf file, requires the Acrobat reader) which provides the details.
Using this model as a guideline, we have attempted to begin creating a user friendly, Windows based CPOPR. This is a work in progress. Currently, the program is usable as a means of maintaining a problem list, data for each problem, and progress notes. Typing or dictation (using dictation software) can be used for data entry. The program uses a simple point and click user interface (I use a touchscreen laptop and that works well). Each item of medical data, where appropriate, is keyed to a specific problem in the problem list. In this prototype, patient data are stored in an "Access" type database; a different database structure would probably be required for scalability.
Here are a few screenshots and details of our "CPOPR" project. (There are several large images on this page so it may load slowly, depending on your connection.) If you have further interest in this, or advice or suggestions, please don't hesitate to contact us.