Applying ASTM E31 Standard Guidelines for Modeling the Sao Paulo University Hospital Computerized Medical Record: Comparing the Real World with the E1384-96 Described Standard Model

Background. In this paper we describe the application of the ASTM committee E31 standard guidelines for implementing a model for a computerized patient record [1]. Sao Paulo University Hospital is updating its clinical information systems and we intend to use international standards to facilitate the implementation and the integration of the new system [2]. This university hospital has six institutes that account for different specialties. Each of these institutes have some particularities regarding their own patient records. The objective of this project was to identify the information formats that were common to every institute, regardless their specialties, in order to design a general model. Our research hypothesis is that the guidelines described by standard E1384-96 can be applyed to help in the identification of such general characteristics and segments, in designing an object-oriented informational model and in saving time in the reengineering process. The methodology to test our hypothesis was: first, we have analysed the currently used paper forms of our hospital as the source material; second, we have built a current model; third, we compared the paper model with the E1384 guidelines. There are about three hundred forms used in the current patient record, plus about other three hundred forms for the administrative processes. The paper forms were grouped into classes of documents. Then, we have used the segments and the objects described by ASTM E31 reference standard E1384-96 for comparing the content and structure of the patient record found in our hospital with the computer-based model described by the standard.