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An electronic medical record system with direct data-entry and research capabilities
S A Salenius1, L Margolese-Malin, J E Tepper
1Department of Radiation Oncology, University of North Carolina Hospital, Chapel Hill.
International Journal of Radiation Oncology, Biology, Physics
|January 1, 1992
Summary
This study introduces an electronic medical record system for radiation oncology that overcomes common barriers like cost and data errors. The user-friendly database efficiently manages patient data and supports research analysis.
Area of Science:
- Medical Informatics
- Radiation Oncology
Background:
- Transitioning from paper-based to electronic medical records (EMRs) is essential but faces challenges including high costs, inefficiency, data entry errors, and physician resistance.
- Existing EMR systems often require significant investment in hardware, software, and dedicated data entry personnel, hindering widespread adoption.
Purpose of the Study:
- To develop and evaluate a novel database system that addresses the limitations of current electronic medical record systems in radiation oncology.
- To create an efficient, user-friendly, and cost-effective electronic radiation oncology chart that integrates transcription and data entry.
Main Methods:
- Developed a database system running on a local area network using a commercial relational database package.
- Integrated features for capturing all dictated notes, including consultation, treatment, and follow-up reports, with built-in data validation upon entry.
- Employed a user-friendly mouse interface with features like pull-down menus and pop-up lists, minimizing training requirements.
Main Results:
- The system has been operational for 1.5 years, managing data for over 2,000 patients.
- Successfully combined transcription and data entry, eliminating the need for dedicated data entry clerks and reducing costs.
- Demonstrated efficient data retrieval, enhanced data accuracy through validation, and provided custom features like audit trails and physician tracking.
Conclusions:
- The developed database system effectively overcomes common barriers to electronic medical record adoption in radiation oncology.
- The system offers a cost-effective, efficient, and user-friendly solution for managing patient data and facilitates research through data export capabilities.