With the increasing complexity of ambulatory care, paper medical records often fall short of providing complete and timely information. We have developed an On-Line Medical Record (OLMR) to meet this challenge. Our integration of various departmental systems with the OLMR has led to a significant increase of function for the clinician.
The OLMR supports a central, patient-oriented database using a relational architecture. The database stores both free text and structured data from a variety of sources. A single registration system front-ends all patient care systems so that these systems share common identifiers for patients and encounters. A microcomputer "Input Manager" controls the flow of data into the database including updates, addenda, and deletions. Access to the database is available via a health center-wide network using 3270 terminal emulation. The application provides both historical and categorical views of patient data. These functions, combined with registration and scheduling, form a "clinical core" to support outpatient care.
The OLMR currently receives data from more than 10 sources including patient demographics, laboratory, radiology, cardiology, inpatient transcription (discharge summaries, operative notes), outpatient transcription (clinic notes, letters to referring physicians), and several specialized systems (endoscopy, radiation oncology). There are currently over 750 clinicians and staff using the system. During the next year we plan to develop a clinical workstation based on a graphical user interface. At that time we will begin to promote direct input of structured data by clinicians (medications, problems, allergies).
Our relatively "low-tech" approach to computer-based medical records has been well received. The success of the OLMR has clearly demonstrated that integrated systems are more important than the sophistication of any single component. In the outpatient environment, where data from multiple sources must be correlated over time, our system delivers a ³critical mass² of information to the clinical user.