Clinical records on computer for ambulatory patients CHRISTOPHER D. OLSON, no

Computer systems now are available not only to record patient information but to use that data to help the physician care for patients. Besides maintaining records in a readable form, the computer can provide valuable summaries and access to data from a remote site, increase efficiency of paperwork through avoiding re-entry procedures, and remind the physician to perform preventive, diagnosis-related, and treatment-related procedures. Costs and problems associated with the use of such systems are not unreasonable when compared to the benefits.

The computer has become an important instru-ment for physicians for a variety of purposes. This paper explores the most valuable features of com-puterized records, and some potential problems and costs. Several software programs are described briefly.

See December DO for articles on computers in medicine.

Features Although the ability to read clinical record data is an important feature of computerization, main-tainance of information in a usable fashion, avoid-ance of re-entry of data, and use of data to gener-ate reminders all may be more valuable functions of the electronic record system.

A quick glance at a problem or medication list or, perhaps, a graph of vital signs and critical labo-ratory data can be extremely useful in emergency situations or at any time to review a patient's his-tory. Unfortunately, these lists often are not ~ept, not current, or not readily available . The most likely reason is that it is time consuming to re-write and keep current data that has already been recorded in progress notes. Even if all of these lists and graphs are maintained properly, they often are

Clinical records on computer for ambulatory patients

not available when they are needed (such as in the emergency room or when the patient telephones the physician at home).

A computerized record system can sort data en-tered in a progress note automatically, can main-tain up-to-date problem and medication lists, and even can graph numerical data. It can make these data available with reasonable security to remote sites such as the emergency room or the physician's home. Finally, such data can be used for cross-population searches for research or medication re-call purposes.

Using data more than once is the key to making a clinical computer system cost effective. This fea-ture requires integration with business systems to be most effective. The diagnosis , for example, may be written in the progress notes, on the patient's billing form, on insurance forms, and, perhaps, in correspondence to a consultant or referring physi-cian. Demographic data are used for business and medical purposes. Also, prescriptions must be re-corded on the chart and then rewritten for the phar-macist, who must rewrite the information for the patient. A computer system can, with a few key strokes, help the physician to find the right name, dose, and quantity of the medication, record it, check for interactions, print a prescription (or send it electronically to the pharmacy of the patient's choice), and print instructions for the patient.

Probably the greatest potential for improving quality of care comes from the computer's ability to remind. It has been shown in a study1 on airline pilots that reliance on memory in critical situations is a vital error. An electronic record system can remind us to perform preventive medicine proce-dures (for example, mammography annually for women past age 50), diagnosis-related procedures (for example, electrocardiography annually for pa-tients with a history of myocardial infarction), and treatment-related procedures (for example, potas-sium determinations quarterly for a patient tak-ing a thiazide drug). Potential drug interactions can be identified automatically on entry of a new medication. McDonald and associates2•3 have shown that these actions are taken twice as often when a reminder is provided than when it is not.

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Potential problems and costs Common concerns in using the computer for mem-ory jogging are that the recommendations will be-come out of date or that a particular physician will not agree with them. Medi-Span drug and drug in-teractions data sets are one example of how to keep data current. These sets, which are used by sev-eral systems for prescription writing and interac-tion checks, are updated quarterly at a reasonable cost. Most systems that provide reminders make them either user-defined or user-modifiable. Any system that appears to recommend patient care likely will come under FDA scrutiny in the near future as a "medical device."4

Entering and accessing data efficiently and un-obstrusively also are significant aspects of com-puter use. McDonald5 notes that "most of the labor problems and costs of establishing a medical re-cord system are on the input side," but that much data potentially can be captured from other sources. Further, there is some concern about the intrusion ofthe computer into the physician-patient relation-ship. 6 'lb utilize such functions as printing prescrip-tions and patient information, the physician or nurse must enter some current clinical data, in-cluding new medications and diagnoses, while the patient is present. For access to historic data, a paper summary must be printed for each encoun-ter or a computer terminal must be present wher-ever the physician or nurse sees the patient. There-fore , patients will need to be acclimated to com-puters in this setting as well .

The cost of a basic computer system will be $20,000 to $100,000, and additional personnel time probably will be required. However, Lloyd7 dem-onstrated that in the first year of use in his office, computerization using Duchess software generated more income than outgo and also resulted in fewer patient visits. The increased income was produced by performing recommended tests and preventive measures that had been overlooked previously. Also, computer-generated postcard reminders for flu shots can increase compliance to near 90% (com-munication, S.C. Lloyd, September 1986) from what it is commonly 20%.8 This mechanism can produce significant income. The potential savings in time by avoiding re-entry of data has been discussed pre-viously.

Improved quality of care should decrease costs for patients by preventing serious illness and the attendant high cost of hospitalization and long-term care. The systems themselves are likely to become more affordable as hardware costs continue to drop, methods of data entry improve, and new technology creates greater efficiency. For example,

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TABLE 1. SOURCES FOR SOFTWARE PROGRAMS.

The Consultant Series Medical Software Consortium PO Box 76069 St. Peters, MO 63376 (314) 928-7373

Duchess Corporation 900 Elmwood Columbia, SC 29201 (803) 779-0557

LifeCard International, Inc. (Subsidiary of Blue Cross and Blue Shield of Maryland) Nottingham Centre 502 Washington Ave Suite 300 Towson, MD 21204 (301) 494-4800

Medi-Span 5980 W 71st St PO Box 68875 Indianapolis, IN 46268-0875 (800) 428-4495

Practice Partner Physician Micro Systems, Inc. 2033 Sixth Ave Suite 707 Seattle, WA 98121 (206) 441-8490

Smart Chart Ash Medical Systems, Inc. 2701 B Kent Ave West Lafayette, IN 4 7906 (317) 463-940

The Medical Record (TMR) Database, Inc PO Box 3054 Durham, NC 27705-1054 (919) 493-6969

The Regenstrief Institute for Health Care 1001 W Tenth St Indianapolis, IN 46202 (317) 630-7400

optical storage devices (laser discs) make storage of large volumes of data more affordable. Insur-ance companies and the government also are show-ing signs of interest in supporting such systems. One example is LifeCard, which is owned by Blue Cross and Blue Shield of Maryland.

Available software systems Of the dozen of computerized record systems avail-able, some are simply modified word processors with few features other than recording of data. Sev-eral business systems have begun offering add-on record components. Some of the most sophisticated systems have been developed at universities, these

December 1988/Journal of AOA/vol. 88/no.12

• During controlled clinical studies, patients receiving HYTRIN had a small but significant decrease ( - 3%) compared to placebo in total cholesterol and LDL + VLDL cholesterol fraction.'·2

Total cholesterol

LDL + VLDL cholesterol

HDL cholesterol

Triglycerides

•HYTRIN is not indicated for the treatment of hyperlipidemia.

HYTRIN® (terazosin hydrochloride tablets) Brtef SMmiMry

ACE inhibitors "'5 ..... ..... ...... ......

CLINI CAL PHARMACOLOG Y: PhlrrnacOifynMnics : Clinical siUdies of temosin used in oncr·a-day (majority)

ard b.i.d regimens wit~ I doses usually in th~ ran~;0o~:~:~~~~~afa,\~ f:'~r~!~ ~;~h5~i~: :~t~ro~:;a/i~s~YJ:s~e~; allstudies, Wlthsubsequenttitrationtoaspecifiedlixeddose

Blood pressure responses were measure at the end of the dosing interval (usually 24 hrs.) and effects were shown to persist throughout th e intervaL with usual supine responses 5·1 OmmHg systolic and 3.5·8mmHg diastolic greater than placebo. The responses in 1he standing position tended to be somewhat larger, ahhough th1s was not true in all studies. The magnitude of blood f,ressure responses was similar to prazosin end less then hydrochloroth i· azi~~ lin a single study). In measurements 4 hrs. alter dosing, heart ra.te was u~chang ed . . . .

hoursalterdosing. '

1 olt:r~~~s~t:: 1:sh~~-~~~~~:a;~e~~m~ : silion there i heart rile in the first few hours after dosing. During the first 3 hrs. after

~~f~n:,Js~-ir~ :: 1g!ti~B~~~~ ~fths~o~~c11P~f~~~~~!:~8~~~~c~~~~~~r~0 '4: 0,ufi;1:~~bs~~~~~n~ . or standing sys·

IN DI CATIO NS AN D USAGE: Indicated fo r the tr eatment of hypertension. CONTRAI NDICATIONS: None known. WAR NI NGS: Syncope ud "first-6ose" Eff.et: TtRzosin, Iiiii other elphl -•drtnlflic Wock i'\:1•nts. u n

:;,:,;:-:..!!r.~~,::n.,-:rr:c~~:.eo:::~~ ~ ir~r.:~:;;ir: ln~:-'m!:r::rori~:~~~i:",:!t:O ••• ~i~~'ac~S: !:,n~:.~~r:n":f a'!!':.:,'~~i:~~,;.':~:t:.~~c~':,. ~~.:~s ~,. :,·.·~!i:~~~::~~::~.:::\'y:~~~,:: tHICt, 1ftttough ocnsionaiiJ the syncoPII epiuult ~~ ltHn prtcdtd by stvtre supn.-ntric•lar tlclryc..-dia with heart fi lii of 120- n o ltpm .

• :.o .~~':tiS:.~ lilttlihood of ·~oro~ ·~te,.s;.tv:,:v::-~r~·tl·~~y1ni~~~·::.;.,.~.:~.:: :.~-;: slowty, and add 1 nsivt lflrtts with Cllltion. C1ution p1titnts to IYOtd sit111tions whtrt inj..-y could result duri, intti1tion of thertpy.

do In early studies, ingle oses u t~f!iit/o:':!r:ff;~~~~~ ~::lrv~~ez;a!~i ~~~e::.n~~~~o~:l ~~~~ ;:sn:,!;~giw~~~~~~~e a~~~1izl~!~t·h'~~~~~~r~i~~da~~ in~~~~ ffectsalloccuuedwithin90min. of dosing.

lnmultiple Opat ients. syncopewasreportedin about1%ofpatients. in no case sever ssociat ed w1th early doses.

.J!.!f!t\~':tt:~~'!Jt1i/r.~~~fn'it;a;r~!~:r~C:,~~~~cc-!~~~o=s~~s~~·~:y 'auft:~~!:1~. There is evidtrtc:e tlllt the

PRECAUTIONS: General: Ortltost•tic HTJIG ''"';.,_. While syncope is the most severe orthostat ic effect of terazosin, other symptoms of lowered BP. such as dizziness. lightheadedness and palpitations, are more tommon, occurring in 28% of patients in clinical trials. Patients with occupations in which such events represent potential problemsshouldbetreatedwithpart icularcaution.

~1'f:::~:.n f:d ro·~!~ffd~:~e ao~~:,~:!o~~s it~i~~r r~r sr~c~rs~ 1 a't::r 0t~~o.~;::i~~le~~tf~~\ eJ::;~:~~~~rte~~~.a~~~ after in terrupt ion of therapy w\en treetment is resumed. Caution to avoid situations whtre inJUry could result should syncope occur during initial therapy. Advise to sit or lie down when sy'"/etoms of lowered BP occur and 10 ~~:o~!de:~'~t:!fian~ Sitting or lying pos1tion. Bothersome diuines.s. lighthea edness. or palpitations should be

Tell patients that drowsiness or somnoltnce can occur. requiring caution in people who must dr ive or operate huvymechintry. l6boratory Tests: Small but statistically significant decruses in hematocrit. hemoglobin. WBC. total prote in and albumin were obstrved in clinical trials. The magnitude of decreases did not worsen with time. These findings sug-ge:st the possibility of hemodilution. Drug lntaractions: In controlled trials. terarosin was added to diuretics. and several bell -adrenergic blockers ; no une~rpected inter~ctions were observed. Terazosin has also been used concomitanlly without interact ion in at least

· · {acellmino en . aspir!n. c~dein_e . ibuproftn, !ndo·

llllrs(diazepaml. Carcinogenesis, Mutagenesis, lmp~irment of fertility.- HYTRJN was devoid of mutagenic potential when evaluated in vivo and in vitro.

HYTRIN. adm inistered in feed to rats at doses of 8, 40. and 250mg/kg/ day for 2 yrs .. was associated with a

• Although HDL fraction showed a slight increase from baseline and triglycerides decreased, neither change was significant compared to placebo.'·2

Calcium Beta Oiuretics 3 blockers 3

..... t ..... +-+ t ..... +-+ ..... • • ..... t t

t Average wholesale price.

~~~1'J~,~~~r, 'J~~i~~~!x1."~!~:~m1~n~:d 1~~~~~ed:~:rf&~~7s~~~e},0~~: 1,1at':'!,e,!p~~:1,~~~!~~ ~i~~~W~~~o~!i oncogenic in mice when administered in fe ed for 2 yrs. at a maximum tolerated dose of 32mg/ kg/day.

The absence of muta en icily _in ~ bauer_v of tests, of !Umori enicity of any cell type in the mouse carcinogenicity

lationwasreponedbetwe Oral use for 1 or 2 yrs.

250mg/ kg/day.butnotinratsuposedto phywas observed in dogs dosed with 300 not after 1 yr. whendosedwith 20mg/kg/ Prafn1ncy.- Teratogenic effects : Pregnancy Category C There are no adequate and well-controlled studies in~reg -

~:: n=e~n~~:s t~!t!~:fat7b~fn ~eti:i~:;ni~s ~;~~~~r.1Yri~:s,:~o~~:~ :~~a~~:~~~d . HYTRIN is not mommended uring ~onteratogenic effects : In a peri - and8ost-natal development study in rats. significantly more pups died in the

group dosed with 120mg/kg/day ( > 30 X mu. recommended human dose) than in the control group during the 3-weekpost -partumpenod. Nursing Mothers.- It is not known whether terazosin is excreted in breast milk ; therefore. e ~rercise caution when edministeringterazos intoanursing woman. Padi1tric Use: Safety and effectiveness have not been determined.

~~~:sR:o~d~~~~r~r?:~ilyTrne ~~~eu:~:nge ~~u~1~:i~~~~~~~ig~~e~:.sd:;~d~f~i~~!\~~~ ~f~~~a~!S~a!:~~~~~ri~~~:~ or in combination with other antihJpertens ive agents, at doses ranging from 1 to 40mg. All adverse events reported

~~~Pg ~::·a~t~~~i:ts 5%.'~~:~~~~e ~~:~a~:~scee r~:t~tirarsi~ed~:;:_;o~r:n~rso~ph~!st~~ _f!!~~~~c =~~t~~ns t~~~~~~,~~s~~

y being npon~~r!s 5r~~~~~~sef~~u~~c~0n;~t~~~~:~ rs,::dl0~6~~~~,~ndi~hl~~e!~ l~~~~~&_~b~ l ~d0v~ ~)~~~!a1 ~~~~~:n~~!~o~:ofi>1~~~::!~~

Additional 1 verse reactions ave een reponed, but these arc! not distinguish eble from symptoms that might

t:va~ ~cacs~rl~ ~? l~8l~s:t?!~ts0~t~P~escu:~!~ ::~::~;~iJ~fi~~~f~~~easd::t~~~r~ga!~~re~i~ea;;::r~e:;;~ ':Cd0~~i~ nal pein, abnormal vision, a n~riety. arrhythmia, arthralgia. arthritis, bronchitis, chest pain, c~d sr.mptoms. conjunc -tivitiS, constipation. diarrhea. dry mouth, dyspepsia. epistuis. facial edema. fever. flatulence, f u symptoms. gout, increased cough, insomnie, joint disorder. myalgia, neck pain, phe~ngitis , pruritus, rash , rhinitis, shoulder pain, swuting. tinmtus, urinaryfrequency. urinarytractinfection,vasodilatmn. vomiting. DOSAGE AND ADM INISTRATION: Dose and dose interval (12 or 24 hrs.l should be adjusttd according to BP re -sponse. htitial Dost: lmg at bedtime. Observe the initial dosing regimen strictly to minimize potential for severe hypoten· siveeffects.

~~:: :a~f:n't~ ~:w16'e~necf~~,:~oJ:s!~ ~~h:~vi~~1J: .8bo~~s:~!~ - 2~s~ ald~0~~t'!~~:~~ t~~gr~~ij:fu~~~~ BP eltecl. Doses over 4lrmg have not been studied. Mon1tor ~p at the end of ~osing interval to assure conlrol is maintained. h may be helpful to measure BP 2-3 hrs. aher dosing to see if maximum and minimum responses are similar, and to evaluate symptoms which can result from ucess1ve hypotensive response. If response 1s substan· tially diminished at 24 hrs. consider an increased dose or b.i.d. regimen. If at1"'i1ustr1tion is discontinued for II'Yirll Nys or tone-r. Jtinstitvtl thtr.py us i ~t~ initial dosing fllimtn. In clinical trills, except for the initial dose. thedose was g•veninlhemorning. Ust With Dthtr Dntts : Ceution should be observed when temosin is 1dministered concomitantly with other an-

~~~~~~~~s~r~e~~~~~y~ec!~~~:~!u~:~tt.aag:~~t:lr~~u~~~~ !~~~:~~;~:~X ~~~il~i~~~~!,h,J~~tension. When adding a

Revised: Sept .. 1988 Abbott Hnlth C1re Products, Inc. North Chicago. ll60064 8083873

References : 1. HYTAIN Product Information, Abbott laboratories. 2. Deger G: Effect of terazosin on serUm lipids. AmJMed1986;80(suppi58) :82..S5. 3. Dzau VJ : Evolution of the clinica l management of hypertension : Emerging role of "specific" vasodilators as initial therapy. Am J Med 1987;82(suppi1AI :36-43. 4. Weinberger MH: The effects of antihypertensive therapy on lipids. Cardiovasc Med 1986;11 :10·11 . 5. Ames RP: The effects of antihypertensive drugs on serum lipids and lipoproteins. II. Non-diuretic drugs. Drugs 1986;32:335-357.

t

#1 0 04 DOB 06 / 07 / 43 <45 )

Vis i t Date: , 10/04 / 88 F W DOCTOR NUMBER 1

MS DORTHY GRANT FMD: DOCTOR NUMBER 1

Problems Onset ld Quan Tl'eatmer:t Sttengtr, - -------5!6--------P Start #Ref M 1 ESSENTIAL HYPERTE 401. 90 02 / 83 1 #30 HYDROCHLOROTH IA 25 MGM clr1e QD P 09/BB x3 M 2 ANGINA 413.90 02 / 83 M 3 DIABETES II 250.00 06 / 85 M 4 OSTEOARTHRITIS 715.90 08 / 86 2 #3~~ FELDENE 20 MGM one QD 09/88 x5

New Diagnosis / Treatments

ESSENTIAL HYPERTE CVD : Ama•!t'OS!s __ F,:<cal neu!'o change _ _ TIA _ _ Confus ior,_ CAD : Chest pa!MAngina ___ Chest t1 ghtness_Palpitat ic•r•=-CHF: Edema Orthopnea __ DND _ ___ ...,--,---,-----CRF : Olig•Jt·ia ___ Noch:r'ia _ _ Hematuria __ Malai se _ _ OV D: C! audicati•)n __ Leg pair•s __ Cyanc•:.is __ Co ld_ Cramps_ BP : L.yi(•Q R_ ) __ L _ _ _I __ Sitti nQ R_/ _ L_ / _

BD: Sta~d R __ _ : --~--'--Pulse Ectopics_ F•.•r:di : ___ ___ __ L•mgs: ,·;!es __ CVS : 53 54 Mun,!ur __ _ Abd·:•men: Liver' ed~e Extt'·ern : Pulses_ ~dert~a_

ANGINA Chest Pain: F•·equenc·y Dul'at i"' ' L~:·cc.t iOn Rad i ati or, Pal pi tat i':<r,s Syr,cope s~ CHF

Pt!lse : c;;s: PMI : Mumur·: Gallop : E~ b'e'n : Edema

DIABETES II Hyp.,gl ycemi2 (weak.ness, t achycar•dia, sweats , confiJ'; ion) : ___ _ Hyper•glycernia (polyur· ia, pol)•phasia, we ight loss) sweet bl'eath_ Diet Visi"''-- Feet Infect ior• 8D : P• .. lse : _____ Blo•)d sugar : ___ _ Fur:di : Feet: Ur•i r·e: _____ _

OSTEOARTHRITIS Interval Hx ________________ _ Ac•Jte e~i sodes _____ Sx changes _ _____ _ Funct ior, changes Com p!i ar:ce rneds _____ _

Ger.erallrn,Jscu l.;.skelet al exar•-~--c-c:----:--------CBC _ __ . SMA/CHEM- 12 ______ _ Uriy,a!ysis_ ---·-- Ot net' ________ _

Fig 1. Patient encounter form Duchess software.

make the greatest use of computer intelligence for reminders to perform certain tests or procedures. Some systems incorporate artificial intelligence to help make decisions.

These larger systems may be too large to con-sider for private practice at this time but have the potential for providing the framework for smaller systems. These latter systems, particularly those from Digital Equipment Corporation, mostly are run on minicomputers. Most of the commercially available systems run on mM AT or IDM-compat-ible hardware. Table 1 lists the sources for each software program discussed.

LifeCard The LifeCard is a credit-card-sized, permanent per-sonal medical record that the patient carries so that

Clinica l record on computer for ambulatory patients

information is readily available wherever the pa-tient may be. The system requires a reader/writer and an ffiM personal computer or IDM-compatible equipment for input and output.

Consultant S eries, Smart Chart The Consultant Series and Smart Chart software do not at present integrate with business systems. Each has the capability of storing progress notes, maintaining problem lists, medication lists, and ba-sic numerical data. Smart Chart uses a laptop com-puter to record all of these data on floppy disks while the physician is with the patient. Both can perform prescription writing and provide drug inter-action information. Neither produces any remind-ers but each has some capacity for user-defined re-call. Smart Chart costs about $1,500. The Consult-

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MS DORTHY GRANT #1004 <10 / 04/88> Page: 2

SURVEILLANCE ORDERS SORTED BY DUE DATE DUE

•09/19/85 *09/19/85 •09/19/85 •09/19/85 •02 / 23/86 •02/23/86 •03/23/86 •03 / 23/86 *03 / 23/86 •03/23/86 •03/23/87 •03 / 22/88 •03 / 22/88 •09/ 11 I 88 03/15 / 89 03/15/89 03 / 15/89 02 / 22/90 03/22 / 90 03 / 22 / 90 03 / 22 / 90 03/15 / 91 03 /2 1 / 95

Exam / Test CBC GLUCOSE HGBA1C OCCULT BLOOD BUN CHEST XRAY: PA CREATININE SED RATE <WESTE SMA1 2 STRESS EKG LOV: LIMITED OV ECHOCARDIOGRAM TONOMETRY URINALYSIS COMPREHENSIVE E EKG PAP SMEAR AUDIOM MAMMOGRAM PPD SKIN TEST SEROLOGY T4 TETANUS TOXOID

Freg SEMI AN SEMI AN SEMI AN SEMI AN ANNUAL ANNUAL ANNUAL ANNUAL ANNUAL ANNUAL

2 YRS 3 YRS 3 YRS

SEMI AN ANNUAL ANNUAL ANNUAL

5 YRS 5 YRS 5 YRS 5 YRS 3 YRS

10 YRS

Reason Preventive Care Dx: DIABETES II Dx: DIABETES II Prevent i ve Care Rx: FELDENE Dx: ESSENTIAL HYP Rx: FELDENE Dx: OSTEOARTHRITI Preventive Care Dx: ESSENTIAL HYP Preventive Care Dx: ESSENTIAL HYP Preventive Care Dx: ESSENTIAL HYP Dx: ESSENTIAL HYP Preventive Care Preventive Care Preventive Care Preventive Care Preventive Care Preventive Care Dx: ESSENTIAL HYP Preventive Care

Delete # 8

19 20

----- 5 23 13 22 21

7 15

3 18

4 14 16 12

2 11

6 9

10 17

1

Fig 2. Surveillance order form Duchess software.

ant Medical Record System costs $1,995. The Con-sultant will soon have its own integrated business package (at additional cost).

Practice Partner, Duchess The Practice Partner and Duchess are AT-based soft-ware systems (Duchess is also available for DEC hardware) that have fully integrated clinical and business functions. Both maintain demographics, problem lists, and medication lists and use these data for a variety of purposes. Duchess can per-form prescription writing and give drug interac-tion information.

The Practice Partner will soon be able to do the same. The latter maintains more information, in-cluding notes as well as laboratory and other stud-ies data, and produces flow charts. However, its reminder system essentially is limited to preven-tion. Duchess , on the other hand, concentrates on reminders based on demographics, problems, and medications. It produces a unique paper "encoun-ter form" for each patient visit (Figs 1 and 2). This form lists problems and related treatment, suggests subjective and objective data to be addressed rela-tive to listed problems, and reminds when preven-tive and other diagnosis- and treatment-related

1514

procedures should be performed. This form can be used for updating both the paper and electronic charts.

Both systems can keep information files to be printed for patients when a new drug or different problem is encountered. The cost of The Practice Partner software is approximately $7,000. Duch-ess is sold on a basis of percent of increased prac-tice volume.

The Medical Record, Regenstrief Institute System The Medical Record (TMR) (VAX Minicomputer, Digital Equipment Corporation) and the system at the Regenstrief Institute (Regenstrief medical re-cords) are highly sophisticated systems with all of the capabilities described above. Each requires a significant investment in hardware. The Regen-strief system is not available commercially.

As with any facet of computers, changes in medi-cal systems may occur daily. New systems and new features become available. The government or other third parties may develop a universal record system. Improvements in clarity and ease of ac-cess to data will make systems more usable. Im-proved integration between functions will enhance economy and greater use of reminders will improve

December 1988/Journal of AOA/vol. 88/no.12

quality of care. Health-care providers and patients will come to accept the inclusion as opposed to in-trusion of the computer.

Comments Clinical record systems on computer are to current paper medical record systems as the present sys-tems are to 3 x 5 index cards of the past. The most pressing reason for using computers for medical records is to improve quality of care. With a com-puter to manage data, there is greater and clearer access to information. By reusing data, and, thus, avoiding re-entry, efficiency improves. Further, ef-ficient and clear record systems have become a ne-cessity for medicolegal reasons. Undeniable costs and potential problems are associated with such systems, but these are not insurmountable and are outweighed by the advantages.

1. Drinkwater BL: Performance of civil aviation pilots under conditions of sensory input overload. Aerosp Med 1967;38:164-168.

Clinical records on computer for ambulatory patients

2. McDonald CJ, Hui SL, Smith DM, et al: Reminders to physicians from an introspective computer medical record: A two-year randomized trial. Ann Intern Med 1984;100:130-138.

3. McDonald CJ: Protocol-based computer reminders: The quality of care and the non-perfectability of man. N Eng! J Med 1976;295:1351-1355.

4. Jorgens J, Schneider RH: Regulation of medical device software: Role of FDA. Proceedings of AAMSI Congress 1986, May 1986, Anaheim, Calif, pp 43-46.

5. McDonald CJ: Computer-stored medical records: Their time is nigh, editorial. M.D. Comput 1987;4:7-8.

6. Cruickshank PJ: Patient satisfaction: Is the computer a plus or ami-nus? Update: Computer Med 1983;l(Sept-Oct):42-47.

7. Lloyd SC: Cost benefit analysis of Duchess in a primary care practice. AAMSI, October 1983.

8. Centers for Disease Control: United States Immunization Survey. At-lanta, Department of Health, Education and Welfare, 1979, no 79-8221.

From the Department of Family Medicine, Ohio University Col-lege of Osteopathic Medicine, Athens, Ohio.

Reprint requests to Dr Olson, Family Practice Center, PO Box 310, 20 Susquehanna Trail, Shamokin Dam, PA 17876.

1515