The anatomy of a clinical information system

Clinical management—the inner shell

Patient encounters and consultations —The computer is the sole data handling medium for seven specialised nephrology outpatient clinics and for nephrology inpatient care. During outpatient consultations, data are reviewed on the screen by both doctor and patient. Patients always welcome the chance to see their records, and no complaints or formal requests for release of information have been received from them. Observations, management plans, and prescriptions are entered by the doctor through the keyboard. During ward rounds, a battery powered, wireless terminal provides the clinical team with continuous contact with the database. Inpatient progress notes are dictated and typed into the database within a few hours. Voice recognition software is being evaluated. Dialysis nursing staff access treatment and drug prescriptions, and results of recent investigations, in order to adjust treatment, which they record on the database.

Clinical prompts and reminders —The system presents prompts, reminders, and recommendations on the screen, based on the stored data and on agreed best practice, guidelines, and protocols. For example, the system is constantly monitoring the results of biochemistry tests, and when it detects preset levels of renal failure it issues reminders to consider various management plans, such as immunisation against hepatitis B.17 Important reminders are also printed out automatically at intervals throughout the day. This provides an excellent background for evidence based practice.

Group case review —A report on about 150 patients is automatically printed and provided to each staff member at a weekly meeting, highlighting patients approaching dialysis, indicating the doctor responsible for care of each patient, and showing details of biochemistry, diet, dialysis fistula, suitability for home dialysis, potential for transplantation, operation scheduling, and other data needed for decisions and a smooth change to a life on dialysis. Preparing the report takes two minutes; previously, it took a secretary four to six hours. One terminal is manned during the meeting so questions can be answered and decisions recorded. Patients with specific problems are “flagged.” The flag or marker can be set at any terminal by any staff member, and stays “on” until it is dealt with at the meeting. Operation waiting lists, patient transfers, and deaths are also reviewed. Morbidity, mortality, and other statistical analyses are available.

Monitoring treatment —Urea reduction ratio and urea kinetic modelling18 are used to monitor dialysis. The urea reduction ratio is the ratio of serum urea concentration before and after haemodialysis. Repeated manual calculation is onerous, but, on receipt of correctly timed blood results, the computer automatically displays a graph of the ratio. Before this facility was introduced, only 55% of our haemodialysis patients achieved a urea reduction ratio greater than 60%. This has now risen to 84%.

Calculation of prognosis —The ease of access to extensive data has enabled us to investigate the use of adaptive neural network software in predicting outcomes.19

Clinical administration—the second shell

In the outpatient clinic —All appointments are arranged through the computer terminals, which can display the appointments record of each patient. An appointments list flags patients taking part in clinical studies and trials who may require particular investigations. The system also prepares identifying labels for samples and laboratory request forms. A patient's arrival is recorded into a terminal by a clerk. A nurse measures blood pressure, weight, and, if necessary, height; tests the urine; and enters the results into a terminal. At the start of consultation, the doctor's initials are recorded. A blood sample is usually sent to the laboratories, using the preprinted labels. On leaving, the patient is handed a fresh prescription printed by the system and makes a follow up appointment. Any future need for ambulance transport is recorded, and a weekly transport request list is generated. The time of each event in the patient's progress through the clinic is recorded automatically as data are entered, and this has been used to audit the management of the clinic and compliance with the NHS patient's charter. After the consultation, the doctor dictates a letter to the patient's family doctor. This text is later typed into the system and merged automatically with standard details such as the author's name and with individual data from the database (age, address, diagnosis, results of investigations, prescriptions, etc), which may be processed (such as calculation of estimated creatinine clearance20). Recall letters to non-attenders are generated, with further letters to their general practitioner for persistent defaulters. An inpatient discharge summary is similarly produced on discharge.

Administrative reminders —As a patient progresses through the clinic the system prompts appropriate staff to complete outstanding tasks. Examples are reminders about missing diagnoses, telephone numbers, details of the family doctor or blood group, or to prepare an outstanding discharge letter. Correspondence and administrative chores are therefore kept up to date. As a final check, a list of missing data is produced daily for the unit administrator, who has a vested interest to keep the list vanishingly small.

Clinical audit —The database inquiry language is used to produce automatically both ad hoc and preprogrammed clinical audit reports. Most Scottish renal units have computer systems with electronic links to a Scottish renal registry database, where national comparative clinical audit reports are produced.21

Tracking inpatients —The changing locations of inpatients treated by the department are shown on a summary screen updated by clinical staff.

Other forms of clinical administration —The system is used to ensure compliance with advice from bodies such as the Committee on Safety of Medicines, the office of the UK chief medical officer, and drug companies on issues such as on flu immunisation or withdrawal or substitution of drugs. The necessary letters to patients and their family doctors are generated automatically from the database, usually within 24 hours.

Many routine administrative tasks require attention to fine detail and may be unfamiliar to junior staff. For example, after the death of a patient a doctor may have to record confirmation of death, complete the death certificate, report to the procurator fiscal (in England, the coroner), meet relatives, request a necropsy, notify the family doctor, cancel prearranged outpatient visits, treatments, and transport, alter ward bed state, remove the patient from waiting lists (such as outpatient and transplant), update morbidity and mortality reviews, cancel current prescriptions, and initiate a discharge letter. These actions are all carried out or prompted by the system when it is notified of a patient's death.

Clinical services—the third shell

Investigative services —The most valuable interface is the automatic receipt and management of laboratory results, already described.

Treatment —Inpatient and outpatient prescriptions for drugs, diet, enteral and parenteral nutrition, and dialysis are recorded, as well as changes to surgical waiting lists.

Pharmacy —Inpatient prescriptions are entered by medical staff at terminals. The hospital pharmacists can review and advise on these prescriptions using terminals in their office.

Dietetics —The hospital dietitians record dietary histories on the system, together with anthropometric measurements, results of indirect calorimetry, dietary prescriptions, and advice given.

Social work —The system is used to provide information for and referrals to the social worker, who has access to appropriate areas of the system.

Transport —Requirements for ambulance transport are entered on the appointment screen.

General management—the fourth shell

The system holds complete data about each patient's status and progress and can therefore produce management information, including monthly workload reports of patients registered, admissions and discharges, consultations, referrals, durations of stay, severity of illness scores, procedures, and use of equipment, drugs, and disposables. The most common reasons for admission have been analysed and their use of resources calculated, costed, and used as the basis for contractual negotiations.