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February 7, 1996

The Gilman Files: Computerized Medical Histories and Automated Physical Examination Reporting System

Author Affiliations

Department of Veterans Affairs Salt Lake City Information Resource Management Field Office Austin, Tex

JAMA. 1996;275(5):409-410. doi:10.1001/jama.1996.03530290081050

Rating: 1.5 (O=worse than a virus, 1=harmless but useless, 2=useful but klutzy, 3=useful, 4=better than most, 5=1 already bought mine).

From stethoscopes to computer equipment, our choices of professional tools are often shaped by cost and personal idiosyncrasy. Yet, the search for better tools is always driven by a desire to make ourselves more efficient and more effective. Efficiency means greater productivity and reduced work burden. Effectiveness, we hope, translates into better patient outcomes. Clinical software, like all other tools, must be evaluated from that perspective.

Software that automates the production of clinical narrative can be based on commercial word processors or designed de novo. Commercial word processors offer versatility, medical spellchecking, high-quality output, and the ability to export completed narratives not only as paper but also as electronic documents. In theory, special-purpose software may be easier to use and may help us connect the meaning of the clinical narrative