Operationalizing a bedside pen entry notebook clinical database system in consultation-liaison psychiatry

Area of Science:

• Psychiatry
• Health Services Research
• Medical Informatics

Background:

• Current computerized data entry systems in consultation-liaison (C-L) psychiatry are not well-received and do not save consultant time.
• Inaccurate and incomplete data collection hinders C-L psychiatry advancement and health services research.

Purpose of the Study:

• To evaluate the effectiveness of a hand-held notebook computer system (MICRO-CARES) for direct, real-time clinical data entry in C-L psychiatry.
• To assess the impact of this system on data accuracy, completeness, and consultant documentation time.

Main Methods:

• Utilized a hand-held notebook computer with Windows PEN ENTRY MICROCARES software for bedside data collection.
• Implemented features for direct data entry, automated coding (ICD-9, Axis III, DRG), patient narrative typing, chart note printing, and literature database access.
• Enabled data transfer via radio frequency or Ethernet to a central archive.

Main Results:

• Consultant documentation time was reduced by half compared to traditional handwritten records.
• The system enhanced data accuracy and completeness.
• Consultees preferred typewritten notes over handwritten ones.
• Hardware cost was less than an optical scanner, with added benefits of report generation and archival searches at the nurse's station.

Conclusions:

• The NOTEBOOK WINDOWS PEN ENTRY MICRO-CARES software offers a practical and efficient solution for C-L psychiatry data management.
• This system improves data quality, reduces documentation burden, and supports research in the C-L psychiatry subspecialty.