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PubMedDate not supplied

Computerized medical records and clinic function.

Formal studies of computerized information systems for ambulatory patients are rare. As part of an evaluation of the effects of such a system on clinic function, we divided the residents in our teaching clinic into a study group with access to COSTAR and a control group with access to conventional medical records alone. Nurses and clerical personnel in the clinic were allowed to use the computerized records only for patients of residents in the study group. We sampled the attitudes of nurses and clerical personnel toward use of the computer and performed detailed time studies of patient flow in the clinic. Responses to questionnaires reflected acceptance of computerization by the personnel sampled, who favored COSTAR records over conventional records, primarily because of the increased availability of information for telephone management and demand care. The residents never became facile users of COSTAR--a problem that we attribute to the infrequency of their clinic sessions. As a result, and because the workloads of residents using COSTAR were larger, waiting times were longer in clinics attended by these residents. Overall, the most intensive users of the computerized medical records were not the physicians. Improved productivity and better use of time among the nurses and clerical personnel were thought to outweigh the residents' perceptions.

Attitude to Computers↗
PubMed1991

Estimating frequency of disease findings from combined hospital databases: a UMLS project.

Merging data from the Salt Lake VA hospital database and the LDS hospital HELP system into a UMLS sponsored unified patient database has demonstrated that distribution of variables within a disease is hospital independent. Although disease prevalence is clearly not the same among hospitals, analysis of data within a disease group across hospitals can be done using such a merged database. This unified patient database would allow study of unusual diseases not possible using data from a single institution.

Databases, Factual↗
PubMed1991

Development of a national genetic services database.

The Council of Regional Networks for Genetics Services (CORN) designed and developed a database collection project to collect minimum data regarding genetic services provided throughout the United States. The data collection project has been designed to improve the provision of services and to determine areas of utilization.

Databases, Factual↗
PubMed1991

Data collection in the Great Plains Genetics Service Network: using limited funds to collect data from centers with varying resources.

The Data Committee of the Great Plains Genetics Service Network (GPGSN) coordinates the collection of data relating to delivery of genetic services in eight states. These states are Iowa, Missouri, Arkansas, Oklahoma, Kansas, Nebraska, South Dakota and North Dakota. The funds allocated to this project by the GPGSN are limited. The distance between genetics service sites is great and the population density in the regions being served is low. The local resources available to the genetics services sites participating in data collection vary from robust to "bare-bones". The approach to solving the problem involved the following. First the committee the data items to be collected were identified and defined. Second, a standard format for transmitting the data to the GPGSN regional coordinating center in Iowa City was developed. Third, the services sites and their resources for collecting data were identified. Fourth, resources were allocated to different sites in a manner that seemed most able to help that center to contribute data to the regional center. Fifth, data were aggregated at the regional center and aggregated data reports were returned to collecting sites. Finally, items were modified in response to the feedback received from the genetics services sites. Although the philosophy is that data collection should be a by-product of providing quality genetic services, the region recognizes that service sites will need help to conform with regional standards. Therefore the region encourages each service site to develop its own method to collect data, and provides assistance to it in getting the data into the regional transmission format.(ABSTRACT TRUNCATED AT 250 WORDS)

Data Collection↗
PubMed1991

Casebook: a system for tracking clinical encounters.

Casebook is a clinically oriented database, written in MUMPS, and designed for recording the clinical encounters of medical students at Harvard Medical School. Its main goals are to 1) increase student use of computer technology, 2) help faculty evaluate the diversity of clinical experiences on their service, 3) provide data to the faculty on the "typical" experience of medical students on their service to aid in the evaluation of the curriculum and, 4) provide report-generation capabilities for the students to improve dialog with their preceptors. Students are able to enter information on "Problems" and "Procedures" selecting from a pop-up menu of medical terms or by entering free text. Casebook is currently in use in the Medicine, OB/GYN, Pediatric and Ambulatory rotations. At sites where the faculty take an active interest in the use of Casebook students perceive it to be valuable and subsequently use it more frequently. It is currently being expanded for use by medical students in their second, third, and fourth years of school.

Attitude to Computers↗
PubMed1992

Half a loaf is better than waiting for the bread truck. A computerized mini-medical record for outpatient care.

We describe a locally developed system for partial computer storage of medical data, called the mini-medical record system. The system produces a typed face sheet prior to each patient visit. The face sheet, which also serves as a progress note, contains patient demographic data, medical problem lists, previous vital signs, allergies, medication profile, and health maintenance reminders. Between regularly scheduled visits, all computerized data are available by computer printout for unscheduled visits to walk-in clinics and the emergency department. Structured reports are generated by the system that describes each resident and faculty members' practice. Quality assurance reports are also available. Since the system draws from several already existing databases, new data entry requirements are modest and cost to the institution is low. Partially computerized systems can be developed inexpensively and are well received in multispecialty practices, where interphysician communication is vital.

Ambulatory Care Information Systems↗
PubMedDate not supplied

Description of a computerized health maintenance tracking system for primary care practice.

This article describes the development of a computerized health maintenance tracking system for primary care practice and its features. Research has shown existing computerized health maintenance tracking systems are unsatisfactory for the average practitioner for these reasons: (1) Data entry is slow or requires duplication of entries for billing purposes; (2) the system is linked to a totally computerized medical record that is expensive and complex to maintain; (3) health maintenance status options are limited to "YES/NO" and do not inform the practitioner of the full range of possible situations; (4) physician reminders are created only for patients with an appointment; (5) patient reminders are not generated on a regular basis regardless of appointment status; (6) it is difficult to change individual and global health maintenance schedules. The system described here downloads demographic and health maintenance data from the practice's billing system. Six health maintenance status options are available: D = done and normal, X = done but abnormal, N = not indicated, R = patient refused, E = done elsewhere, I = abnormal but inactive. A health maintenance status report is created for both the patient and provider once a year, in the month of the patient's birth unless an alternate month has been designated, regardless of the patient's appointment status. Patients are encouraged to make an appointment for overdue health maintenance procedures, unless already scheduled.

Appointments and Schedules↗
PubMed1992

Implementing guidelines in ambulatory practice.

As we understand the process of ambulatory care better, the need to effectively implement standards of practice becomes more apparent. To facilitate successful use of practice guidelines, we have integrated an artificial intelligence system of Medical Logic Modules into our computerized medical record. A rule shell allows rapid development and prototyping of rules which can be practice reminders, information gathering utilities, or standing orders. A set of utilities allows non-programmer clinicians to develop and maintain the rule set. We will demonstrate these enhancements in the context of the comprehensive patient record.

Ambulatory Care↗
PubMed1977

Immunisation.

Explore the source record for details and available documents.

England↗
PubMedDate not supplied

The Clintrac medical data system.

Basically, this is a clinical data entry program. Billing is added for convenience. It would be fine for a practitioner working in an institution with an existing billing department. You could certainly use it in a private office as an all-purpose workhorse, but you'd need to apply the criteria I listed in a recent article in this jouranl [1] to rate the accounts receivable section when it's complete. Dr. Bryner says he has done this and finds my criteria met by this package. The program shows much hard work and a good deal of promise. It strikes at the core of one of today's greatest frustrations. What's more, Dr. Bryner is dedicated to improving it as he goes along. The system is sold by Clintrac, Inc., 814 Main St., Yreka, CA 96097. The company is an IBM Business Partner. The current price is $14,000. It is only sold directly by the vendor, who has four employees and has sold four systems as of January 22, 1991. Extra costs are assessed for additional users ($1,500 each), specialty modules ($2,000 each), and support (12% of price per year). Updates are included in the support price. IBM is arranging to lease the system. The current version number is 2.0B.

California↗
PubMed1991

Computerised information exchange in health care.

The slowly increasing use of computers in the management of general medical practices may be greatly accelerated if new technologies for the storage and transfer of information are introduced. Electronic data interchange promises to speed the transfer of medical data, insurance information and payments. Smart cards promise a portable, up-to-date, confidential medical record that can be carried by patients. However attractive these new systems may be to computer suppliers and government bureaucracies, it is not certain that they will be as attractive for the general practitioners who will be required to implement the changes. Smart cards may exacerbate problems with the ownership and privacy of data, rather than guaranteeing confidentiality and control. Data exchange through a computer network may allow many information services not actually essential to general practice, while creating serious new possibilities for breaches of privacy. Costs in implementing the new technologies for general practices may outweigh any gains in efficiency, which could in any case be achieved through better use of paper records. The Health Insurance Commission may see advantages in the collection of data on the diagnoses of patients that can be used in epidemiological studies and in the control of overservicing, but there will be practical limitations on the reliability of the data collected by this means. General practitioners should carefully consider their attitude to these new technologies before suppliers, governments and others make their record-keeping decisions for them.

Attitude of Health Personnel↗
PubMed1990

Computerizing medical records: software criteria for systems to document patient encounters.

It is difficult to design and build computer systems to document medical care, especially if the entries are to be made by health care professionals. Not all software approaches are equally well suited to the task. Twenty-one specific software characteristics were identified that promote efficient development and support clinical needs. Using a software tool that satisfied these characteristics, we developed a computerized medical chart system that physicians can use to write notes and document patient encounters. The success of this system was due to a good fit between the basic capabilities of the software approach and the requirements of the project. These criteria can serve as the starting point for evaluating or developing other software applications that depend on physician input of clinical information.

Documentation↗