OBJECTIVES: To investigate the issues raised in applying a preliminary version of the GALEN compositional concept reference (CORE) model to a series of radiographic reports, and to demonstrate that the same underlying concept model could be used in conjunction with both a detailed, fine-grained model of medical records based on that used in the PEN&PAD project and with other more conventional medical-record models. DESIGN: Following analysis and representation of concepts from a set of reports, a single report was taken as a "case study." This report was analyzed in detail in its entirety and represented using each of the medical-record models. RESULTS: The reports were successfully represented within the limits of the study, but a number of significant issues were raised. CONCLUSION: The compositional approach plus the PEN&PAD medical-record model allowed detailed information in the radiographic report to be represented, including information about the inferences and the clinical process. The resulting representation was large, and more compact representations may be necessary for some systems. Alternative encapsulations of the information as might be used in such systems were successfully prepared. The compositional approach avoided many issues that often cause controversy in the design of traditional coding and classification systems, but it raised other issues, including the handling of ambiguity and underspecification, linkage to information not explicitly present in the report, and questions concerning the focus of individual concepts. All work is preliminary and definitive conclusions await further studies and systematic evaluation.

It is argued that current clinical information systems incorporate oversimplistic, prescriptive data models that are not faithful to clinicians' observations. A non-prescriptive descriptive semantic formalism, Structured Meta Knowledge (SMK), which unifies a terminological knowledge base with controlled assertional capabilities with the medical record and supports the semantic control necessitated by such an approach, is proposed. The three-layer model of categories, individuals, and occurrences described is more appropriate to medical applications than the two layers of classes and instances. The application of SMK in predictive data entry is considered.>

The goal of the PEN&PAD project is to design and develop a useful and usable medical workstation for day–to–day use in patient care. The project has adopted a user centred approach and direct observations of doctors, participative design and Formative Evaluation have therefore been an integral part of the process of software development. Indeed, doctors have been involved from the earliest stages of the project. The project has focussed on British General Practitioners, but the methods which have been evolved are general. This paper describes the strategy by which doctors can be involved in the successful design and development of a medical workstation.