Structured electronic physiotherapy records

Abstract 

Background

With the introduction of the electronic health record, physiotherapists too are encouraged to store their patient records in a structured digital format. The typical nature of a physiotherapy treatment requires a specific record structure to be implemented, with special attention to user-friendliness and communication with other healthcare providers.

Objective

The objective of this study was to establish a framework for the electronic physiotherapy record and to define a model for the interoperability with the other healthcare providers involved in the patients’ care. Although we started from the Belgian context, we used a generic approach so that the results can easily be extrapolated to other countries. The framework we establish here defines not only the different building blocks of the electronic physiotherapy record, but also describes the structure and the content of the exchanged data elements.

Methods

Through a combined effort by all involved parties, we elaborated an eight-level structure for the electronic physiotherapy record. Furthermore we designed a server-based model for the exchange of data between electronic record systems held by physicians and those held by physiotherapists. Two newly defined XML messages enable data interchange: the physiotherapy prescription and the physiotherapy report.

Results

We succeeded in defining a solid, structural model for electronic physiotherapist record systems. Recent wide scale implementation of operational elements such as the electronic registry has proven to make the administrative work easier for the physiotherapist. Moreover, within the proposed framework all the necessary building blocks are present for further data exchange and communication with other healthcare parties in the future.

Conclusions

Although we completed the design of the structure and already implemented some new aspects of the electronic physiotherapy record, the real challenge lies in persuading the end-users to start using these electronic record systems. Via a quality label certification procedure, based on adequate criteria, the Ministry of Health tries to promote the use of electronic physiotherapy records. We must keep in mind that physiotherapists will show an interest in electronic record keeping, only if this will lead to a positive return for them.

Keywords: Medical record systems, computerized [Mesh], Physical therapy [Mesh], Information systems [Mesh], XML, Internet