Skip to main content
PMC home page
Proceedings of the Annual Symposium on Computer Application in Medical Care logoLink to Proceedings of the Annual Symposium on Computer Application in Medical Care
. 1991:114–118.

Outpatient medical records for a teaching hospital: beginning the physician-computer dialogue.

C Safran 1, C Rury 1, D M Rind 1, W C Taylor 1
PMCID: PMC2247506  PMID: 1807568

Abstract

We have developed an outpatient medical record (OMR) system designed to facilitate direct physician interaction with the computer-based medical record. During the first two years the system was in use, staff physicians, residents, and nurse practitioners entered 15,121 active and 1996 inactive problems for 3524 patients, and 12,651 active medications and 1894 discontinued medications for 3430 patients. These clinicians entered 20,321 items on health promotion and disease prevention screening sheets and with the help of automatic updating by the computer an additional 21,897 entries on screening sheets were made for 8686 patients. On the computer, clinicians wrote more than twice as much--10.9 words per problem, in contrast to 4.3 words per problem in the paper record (p less than 0.0001, Student's t). We conclude that clinicians perceived the computer-based problem list to be more valuable than its paper counterpart.

Full text

PDF
114

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Berarducci A. A., Delbanco T. L., Rabkin M. T. The teaching hospital and primary care. Closing down the clinics. N Engl J Med. 1975 Mar 20;292(12):615–620. doi: 10.1056/NEJM197503202921205. [DOI] [PubMed] [Google Scholar]
  2. Bleich H. L., Beckley R. F., Horowitz G. L., Jackson J. D., Moody E. S., Franklin C., Goodman S. R., McKay M. W., Pope R. A., Walden T. Clinical computing in a teaching hospital. N Engl J Med. 1985 Mar 21;312(12):756–764. doi: 10.1056/NEJM198503213121205. [DOI] [PubMed] [Google Scholar]
  3. Bleich H. L., Safran C., Slack W. V. Departmental and laboratory computing in two hospitals. MD Comput. 1989 May-Jun;6(3):149–155. [PubMed] [Google Scholar]
  4. Dambro M. R., Kallgren M. A. Drug interactions in a clinic using COSTAR. Comput Biol Med. 1988;18(1):31–38. doi: 10.1016/0010-4825(88)90054-6. [DOI] [PubMed] [Google Scholar]
  5. Fordham D., McPhee S. J., Bird J. A., Rodnick J. E., Detmer W. M. The Cancer Prevention Reminder System. MD Comput. 1990 Sep-Oct;7(5):289–295. [PubMed] [Google Scholar]
  6. Frame P. S. Can computerized reminder systems have an impact on preventive services in practice? J Gen Intern Med. 1990 Sep-Oct;5(5 Suppl):S112–S115. doi: 10.1007/BF02600855. [DOI] [PubMed] [Google Scholar]
  7. Grossman J. H. An ambulatory medical record system for patient care and health care management. Methods Inf Med Suppl. 1972;6:375–382. [PubMed] [Google Scholar]
  8. Hammond K. W., Prather R. J., Date V. V., King C. A. A provider-interactive medical record system can favorably influence costs and quality of medical care. Comput Biol Med. 1990;20(4):267–279. doi: 10.1016/0010-4825(90)90052-q. [DOI] [PubMed] [Google Scholar]
  9. McDonald C. J., Blevins L., Tierney W. M., Martin D. K. The Regenstrief medical records. MD Comput. 1988 Sep-Oct;5(5):34–47. [PubMed] [Google Scholar]
  10. McDonald C. J., Hui S. L., Smith D. M., Tierney W. M., Cohen S. J., Weinberger M., McCabe G. P. Reminders to physicians from an introspective computer medical record. A two-year randomized trial. Ann Intern Med. 1984 Jan;100(1):130–138. doi: 10.7326/0003-4819-100-1-130. [DOI] [PubMed] [Google Scholar]
  11. McDonald C. J., Murray R., Jeris D., Bhargava B., Seeger J., Blevins L. A computer-based record and clinical monitoring system for ambulatory care. Am J Public Health. 1977 Mar;67(3):240–245. doi: 10.2105/ajph.67.3.240. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. McDonald C. J. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med. 1976 Dec 9;295(24):1351–1355. doi: 10.1056/NEJM197612092952405. [DOI] [PubMed] [Google Scholar]
  13. McDonald C. J., Tierney W. M. Computer-stored medical records. Their future role in medical practice. JAMA. 1988 Jun 17;259(23):3433–3440. [PubMed] [Google Scholar]
  14. McDonald C. J., Tierney W. M. Research uses of computer-stored practice records in general medicine. J Gen Intern Med. 1986 Jul-Aug;1(4 Suppl):S19–S24. [PubMed] [Google Scholar]
  15. McDonald C. J., Wilson G. A., McCabe G. P., Jr Physician response to computer reminders. JAMA. 1980 Oct 3;244(14):1579–1581. [PubMed] [Google Scholar]
  16. Murray M. D., Brater D. C., Tierney W. M., Hui S. L., McDonald C. J. Ibuprofen-associated renal impairment in a large general internal medicine practice. Am J Med Sci. 1990 Apr;299(4):222–229. doi: 10.1097/00000441-199004000-00002. [DOI] [PubMed] [Google Scholar]
  17. Norman L. A., Hardin P. A. A multipurpose, computer-assisted program to improve ambulatory medical care: a preliminary report. QRB Qual Rev Bull. 1990 Oct;16(10):365–372. doi: 10.1016/s0097-5990(16)30392-x. [DOI] [PubMed] [Google Scholar]
  18. Ornstein S. M., Garr D. R., Jenkins R. G., Rust P. F., Arnon A. Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services. J Fam Pract. 1991 Jan;32(1):82–90. [PubMed] [Google Scholar]
  19. Safran C., Porter D., Lightfoot J., Rury C. D., Underhill L. H., Bleich H. L., Slack W. V. ClinQuery: a system for online searching of data in a teaching hospital. Ann Intern Med. 1989 Nov 1;111(9):751–756. doi: 10.7326/0003-4819-111-9-751. [DOI] [PubMed] [Google Scholar]
  20. Safran C., Slack W. V., Bleich H. L. Role of computing in patient care in two hospitals. MD Comput. 1989 May-Jun;6(3):141–148. [PubMed] [Google Scholar]
  21. Safran C. The mouse-waving principle. MD Comput. 1991 Jan-Feb;8(1):4–4. [PubMed] [Google Scholar]
  22. Slack W. V., Peckham B. M., Van Cura L. J., Carr W. F. A computer-based physical examination system. JAMA. 1967 Apr 17;200(3):224–228. [PubMed] [Google Scholar]
  23. Slack W. V. Remembrance, thanks, and welcome. MD Comput. 1989 Jul-Aug;6(4):183–185. [PubMed] [Google Scholar]
  24. Weed L. L. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593–600. doi: 10.1056/NEJM196803142781105. [DOI] [PubMed] [Google Scholar]
  25. Wilson G. A., McDonald C. J., McCabe G. P., Jr The effect of immediate access to a computerized medical record on physician test ordering: a controlled clinical trial in the emergency room. Am J Public Health. 1982 Jul;72(7):698–702. doi: 10.2105/ajph.72.7.698. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Proceedings of the Annual Symposium on Computer Application in Medical Care are provided here courtesy of American Medical Informatics Association

RESOURCES