The Regenstrief Medical Record System: a quarter century experience
Section snippets
Background/history
We began our efforts to create a computer-stored medical record in 1972, with Dr Charles Clark and his 35 diabetes patients, at what was then called Marion County General Hospital. We thought that we could capture all patient data on this small number of patients through manual methods, and that it would take about a year to complete the medical record. Then we could get on with the ‘fun’ part of this effort—automated diagnoses and management. We built programs to enter patient data, to store
Overview and methods
The Regenstrief Medical Record System (RMRS) is large, fast, comprehensive, long term and introspective [8]. It contains more than 200 million separate coded observations, 3.25 million narrative reports, 15 million prescriptions and 212,000 electrocardiographic (EKG) tracings. It carries data for more than a 1.3 million patients, and it can display the records for any one of these patients in less than a second. It is used by more than 1300 medical center nurses, 1000 physicians and 220 medical
Data capture—the difficult side of medical record systems
Any demonstration system, pre-loaded by hand with clinical data, will illustrate the great benefits of EMRs—i.e. visit notes, flowsheets, graphs and statistics. However, demonstration systems do not convey the effort needed to capture such data from processes within a live institution. Though the increasing availability of HL7 interfaces and universal codes for clinical variables (LOINC) [18] and other clinical concepts (SNOMED [20], Read [22] codes) has made it easier to capture clinical data,
Clinical outputs for patient care
The computer record provides a number of ‘by patient’ reports that can be obtained as soft (video terminal displays) or hard copies to serve care providers. Hard copy continues to be popular in the clinic because it is easy to produce paper reports automatically at check-in.
Three reports are typically produced for each clinic visit: the encounter form described above, a flowsheet of all of the structured medical record data, and a specialty snap shot. This latter report is designed to provide
Reminders and informational feedback to providers
The computer provides informational feedback at many points in the order writing process [24]. When physicians enter a problem into the workstation, the computer tailors the order menus to that problem (see Fig. 15 for the treatment order menu for peptic ulcer disease). Physicians can generate an order simply by choosing one of the pre-formed options after entering the patient’s problem. When the user enters an order, the computer pops up an information window that reports the order’s price,
Search and retrieval capabilities and retrieval capabilities—cross-patient reports
Users with appropriate privileges can perform cross-patient searches for IRB-approved research and quality management purposes [35]. They can use the CARE language [7] to search the entire data base, a subset of the data base, or several institutions’ databases for patients whose EMR contains particular patterns of data. This same system can be used to implement reminder rules or queries.
Fast retrieval is a second way to search the data base. It uses direct indexes by clinical variable (e.g.
Conclusion and future challenges
Since we began in 1973, physicians have always been happy with the retrieval and display aspects of our medical record system. Having immediate access to all diagnostic reports, operative notes, discharge summaries, drug records and a large portion of other notes is a joy compared to the slow and erratic alternatives of requesting the hard copy chart or calling each diagnostic service for the results. The happy reaction we have received from physicians and other health professionals about our
Acknowledgements
This work was performed at the Regenstrief Institute for Health Care, Indianapolis, IN, and was supported in part by the Agency for Health Care Policy and Research (Grant HS 07719) and the National Library of Medicine (Contracts N01-LM-4-3410 and N01-LM-6-3546).
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