Development of a complete electronic medical record in an academic institution

Abstract

I n veterinary medicine a complete electronic medical record (EMR) should contain all information (eg, demographic, financial, medical/surgical, diagnostic, and pharmaceutical) related to all visits of a patient as well as owner contact and billing information. It is clear that such a complete EMR and the ability to retrieve and use the information it contains in an integrated manner would provide operational economies, improve patient care, and enhance teaching. We embarked on a project to develop such a record in an academic institution. This article describes our approach and how the EMR is currently being used in academic medicine. Development of the Hospital Information SystemThe effort to develop a computerized patient record system for the veterinary medical teaching hospital (VMTH) began about 20 years ago but progressed with difficulty, largely because of a lack of human resources. The event that triggered the commitment of substantial resources toward development of the EMR was the need for the VMTH to become autonomous from the services of an outside accounting firm. The firm was unable to provide the level of detail and flexibility required for the fiscal management of the VMTH. The decision was made to hire programming staff to write a hospital information system (HIS) specifically designed to combine the objectives of clinical information management with those of hospital administration and patient billing in a single integrated system. The existing medical record system served as the foundation for this effort. The computing platform chosen was the Massachusetts General Hospital Utility Multiprogramming System (MUMPS), because it had a proven record of success in medical computing, provided a flexible programming environment and strong retrieval capabilities, and did not require a mainframe computer. 1,2 A decision was also made that the primary force guiding EMR development would be to meet the needs of the users it was designed to serve: the VMTH faculty, students, and staff.In the old accounting system all financial entries were made centrally in cashiering. At that time a copy of each completed procedure request was hand routed to cashiering, where it was manually posted. As an initial step toward facilitating diagnostic reporting, VMTH staff in the various services who already had responsibility for entering billing information onto the routing slips were assigned responsibility for entering that information directly into the HIS. This point-ofservice entry concept was adopted as an objective for development for all components of the EMR. Point-ofservice entry was defined as assigning responsibility for information entry to the individual closest to the source of the information. Software tools were designed that enabled these individuals to make the entries directly into the electronic record instead of the paper record. For example, admissions staff entered demographic information as they acquired information necessary to make an appointment, usually during a telephone conversation with t...

Approaches to canine health surveillance

“…The ‘Independent Inquiry into Dog Breeding’ report cited primary-care practice electronic clinical data using standardised coding of diagnoses as the optimal data source for reliable prevalence estimation [ 7 ]. However, early attempts at large-scale electronic surveillance struggled to cope with the large volumes of clinical data collected [ 19 ] and initial veterinary PMSs did not enforce structured coding systems [ 97 ], although there is now evidence that practising veterinarians accept a clinical rationale for standardised data recording [ 98 , 99 ].…”

A method for extracting electronic patient record data from practice management software systems used in veterinary practice

“…Unfortunately the different methods described here utilised to obtain veterinary data are not necessarily transferrable across these PMSs due to differences in database structure. There are many different commercial PMSs on which information from veterinary primary care consultations is kept [ 2 , 4 , 16 ]. Therefore it is a challenge to obtain and link data from different PMSs representative of all systems currently in use within veterinary practice.…”

Survey of electronic veterinary medical record adoption and use by independent small animal veterinary medical practices in Massachusetts

“…In human medicine, an ideal EMR system has efficient search and retrieval capabilities, uses standardized diagnostic coding, and protects patient and client confidentiality while maximizing patient health, quality of care, practice efficiency, and profit. 1–4 However, few EVMR models with these capabilities exist in the veterinary medical profession; these include proprietary systems in use by large networks of hospitals, a systems used by veterinary medical teaching hospitals, 1 and commercial programs employed by independent clinics and hospitals. b–e …”

“…17 Electronic veterinary medical record systems available to the veterinary medical profession are believed to include some of these capabilities, although they have not been described as specifically having or lacking these functions. 1,10,13,14 Receiving greater attention recently, however, is the potential of EVMRs to contribute to understanding the epidemiology of animal diseases, including those that have zoonotic potential. 18 A comprehensive literature review in 2001 found that 868 of 1,415 (61%) infectious human pathogens were zoonotic and 132 of 175 (75%) pathogenic species associated with EIDs were zoonotic.…”