Getting the data in: three year experience with a pediatric electronic medical record system

Area of Science:

• Health Informatics
• Clinical Information Systems
• Pediatric Healthcare Technology

Background:

• The Clinician's Workstation (CWS) has been operational for three years, offering comprehensive electronic patient records in pediatric outpatient settings.
• Its implementation involved significant data integration from diverse sources.
• This paper focuses on the design challenges encountered post-implementation.

Purpose of the Study:

• To address design issues in physician and transcriptionist data entry and retrieval within the CWS.
• To evaluate the impact of balancing controlled vocabulary and free text in the electronic patient record.
• To review the consequences of these design decisions on clinical practice, education, and research.

Main Methods:

• Analysis of design decisions made for the Clinician's Workstation (CWS).
• Evaluation of data entry and retrieval methods, focusing on the mix of controlled vocabulary and free text.
• Review of clinical care, education, and research outcomes over three years.

Main Results:

• Successful implementation of a full-functionality electronic patient record system.
• Identification of key design issues related to data entry and retrieval.
• Demonstration of the impact of design choices on various aspects of clinical operations.

Conclusions:

• The Clinician's Workstation (CWS) provides a functional electronic patient record system for pediatric clinics.
• Balancing controlled vocabulary and free text is crucial for effective data management.
• Design decisions significantly influence clinical care, education, and research activities.