2002 Volume 38 Issue 7 Pages 1032-1039
Purpose : The purpose of this article is to describe the development and utilization of a paperless computer-based patient record system (CPR) and explain a proposal made to The Japanese Society of Pediatric Surgeons regarding information technology (IT). Subjects and Methods : Since 1999, Shimane Prefectural Central Hospital has worked to develop a CPR. It is not ready-made, but a continuously changing and expanding system. There remain some points for improvement, such as access speed and quality of digital imaging, however the system offers not only a variety of benefits to physician practice, but safety and convenience to patients as well. During the development process, labor was required to input standard clinical vocabulary into the system. Results and Conclusions : The objectives of the CPR are to contribute to the standardization and quality assurance of medicine. The implementation of the system is a means, not an end. There are many kinds of CPR in Japan now, and a lack of standard software engineering methodologies has interfered with standardization. Strategies for standardizing the CPR were investigated, and a recommendation was provided for approaching the standardization process, at least in the field of Pediatric Surgery, where greater more utilization of IT was proposed.
