Richard Rathe, MD

Associate Professor of Family Medicine and Medical Informatician

Historical Document (1994) – Future Clinical Information Systems

Excepted from the On-Line Medical Record Newsletter, November 1994

Minimal Features for Future Clinical Information Systems

Maintenance of Base

Refers to functions that any new system will need to provide in order to maintain the level of service enjoyed by current users of the On-Line Medical Record (OLMR).

Continued use of a single patient identifier across all systems and data
Continued access to existing archival database (current OLMR data)
Continued access to basic demographic, visit history and scheduling data
Continued hardware independent access to clinical database
Continued ability to print clinical and other data on demand
Continued ability to audit access to clinical data (audit trail)

Continued input from current contributing systems:

  • Transcription Systems
  • Heart Station
  • Laboratory
  • Radiology
  • Pathology

Essential Enhancements

Refers to functions that are necessary in any new system as we move toward increased use of electronic information.

Improved ease of use

  • Minimal steps to login
  • Single password “key” for authentication
  • Sleep / wake functions (maintain current context during sleep)
  • Short period for automatic sleep (5 minutes)
  • Longer period for automatic logout ( 20 minutes)

A unified scheme for recording, coding, and displaying:

  • Vital signs
  • Medication and allergies
  • Problems, diagnoses, and procedures
  • Immunizations and preventions

A unified scheme for identifying, tracking, and reporting to:

  • Primary care provider
  • Consultants
  • Referring physicians
  • “CC” list for each patient

Direct data entry by clinical staff where appropriate

  • Flow sheets
  • Vital signs
  • Telephone encounters
  • Diagnostic coding
  • Electronic signature

A unified scheme for identifying and tracking users

  • New, transferred and terminated employees
  • Passwords and other authentication mechanisms
  • Audit trail of all access to clinical data

More comprehensive data base

  • Emergency room notes
  • Notes from the majority of clinics

Increased use of structured data

  • To ease direct data entry
  • Custom report generation
  • Management and research

Other Enhancements

Refers to functions that would be useful in any new system.

Message systems

  • Clinical alerts
  • Stat results
  • Email consults

On-line documentation

  • Formulary
  • Protocols
  • Policy and Procedures
  • Reference

Archive and research databases

  • Off-line storage of inactive patient data
  • Off-line storage of data for research

Richard Rathe / Pam LaFrentz