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.
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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
Please contact:
John Kirby - University of Manchester
Tel: +44 161 275 6133
E-mail: jkirby@cs.man.ac.uk
Alan Rector University of Manchester
Tel: +44 161 275 6188
E-mail: rector@cs.man.ac.uk
