The PEN&PAD Data Entry System
by John Kirby and Alan L Rector
The PEN&PAD Clinical Entry System is a new user-friendly way to input detailed patient information into existing Electronic Healthcare Records. It is based on ten year's user-centred design by the Manchester Medical Informatics Group using the GALEN approach to medical terminology. The initial system is designed for UK general practitioners, but the content can be tailored to other specialties.
The PEN&PAD data entry and medical records system was developed in cooperation with clinicians as part of a programme of user centred design. Early on, the project concluded that simple hierarchical coding schemes such as Read 2 or ICD-CM have two defects which seemed insurmountable:
- navigating to terms is slow and cumbersome because of the size and structure of large coding schemes
- any list of fixed terms, however long, fails captures the detailed content required for clinical care. Clinical care requires that patients be described rather than labelled.
The PEN&PAD alternative is based on building up descriptions of patients from elementary terms using the techniques in the GALEN project. (See article in this issue)
The main features of the design are:
- graphical point-and-click selection of clinical topics
- automatic generation of data entry forms for each topic
- user customisation
- generation of readable natural language expressions from the data entered
- automatic production of codes for central reporting or remuneration, eg ICD, Read, etc. according to local requirements.
Entering data using the PEN&PAD DES takes place in two stages. First a presenting complaint or clinical topic is selected; then further details may be entered on a data entry form.
The PEN&PAD Topic Selector
The presenting complaints can be selected in three ways:
- the user can double click on any item on the existing record to get a form for a new episode of the same event, eg when a patient returns with another episode of acute bronchitis, the doctor need only double click on the problem or presenting complaint from the previous episode
- the user can select from a list of common presenting complaints which each user can tailor to their own needs as they work
- the user can call up the graphical Topic Selector.
On the graphical Topic Selector, symptoms and diseases are associated with body locations, so that when a location is selected only symptoms or diseases appropriate to that location are displayed.
Once a presenting complaint is selected, a form is generated automatically from the knowledge base. Forms contain a variable amount of information divided into descriptors (eg severity, progress, onset, aggravating and relieving factors, etc.), associated symptoms, examinations, and diagnoses. Multiple levels of forms are controlled by buttons for more details, other symptoms, further examinations, etc. Users enter as much or as little detail as required. A typical structured record produced by this mechanism in a few seconds worth of mouse clicks might be:
Greater or less detail can be entered as required. A more discursive presentation is also available.
Underlying Terminology Services
At the heart of the PEN&PAD Data Entry System is a Terminology Server based on the GALEN technology.
Multilingual versions of the underlying technology have been developed in the GALEN project currently covering English, French, Dutch, and German with further languages expected.
The PEN&PAD Data Entry System has now been redeveloped as a commercial product to provide a re-usable component for Electronic Healthcare Record Systems. In the first instance, it will operate in conjunction with the VISION system marketed by VAMP Health Limited.
Further information can be obtained at http://www.man.ac.uk/vuman/vumanv25.htm
John Kirby - University of Manchester
Tel: +44 161 275 6133
Alan Rector University of Manchester
Tel: +44 161 275 6188