INFORMATION MANAGEMENT IN AMBULATORY CARE: THE NURSE AND COMPUTERIZED RECORDS Robin Stoupa RN BSN Judith J. Warren RN PhD June E. Bonk RN BSN James R. Campbell MD Department of Internal Medicine University of Nebraska Medical Center 600 South 42nd Street Omaha, NE 68198-3333 (DEC0) family of minicomputers, but in recent years has come available through the COSTAR Users' Group (CUG) on a variety of platforms, including mainframes and microcomputers of the IBM0 family. Due to new hardware options and the low cost of the software, recent surveys by CUG have demonstrated that a majority of new users are installing microcomputer systems in small and medium size offices. These trends have necessarily led to changes in the appearance and function of the system nationwide. Computerized ambulatory medical records have been in use in our Internal Medicine Clinic, since 1983 and more extensively in the medicine specialties and remote sites since 1987. We first installed COSTAR on a DEC PDP0 11/34. Computer expansion to a MicrovaxO 3900 with 2.0 gigabytes of computerized patient records has been necessary as acceptance and use of the system has grown. Successful use of COSTAR in ambulatory care at our site has led to implementation of enhanced versions of the software in Medicine Specialty, Cancer Center, and Surgery/Transplant clinics. Connections to other campus information systems for capture of laboratory and radiology information has dramatically increased the utility of COSTAR for clinic staff. These wide area network links are available through a hybrid network architecture across a token ring campus-wide superhighway. Computerized patient records offer accessibility to information which is impossible with a paper record, thereby promoting efficiency and creating new possibilities for practice management. [2] Past research [4,5,6] has demonstrated that nurses spend substantial amounts of time managing and coordinating information for patient care both in clinic and via telephone. Due to their interest as high
Abstract
The ambulatory office setting is increasingly becoming a central focus of patient care. The nursing staffare integral to patient care management in this environment. They arefrequently the heaviest users of medical records and are generally early advocates of well designed computer records systems. As our implementation of a Computer Stored Ambulatory Record (COSTAR V@) has grown in complexity and utility, reorganization of the record and development of new features to support nursing has become critical. This demonstration will show how nursing information management has changed using a variety of computer record tools, including features of exam room data entry, specialized nursing displays and problem based patient summaries. Specific items for demonstration will include: nursing
check-in module, rule driven nursing history program, prescription refillfunctions, documentation and billingfor nursing procedures, nursing telephone management functions, a modulefor management of anticoagulation and document retrieval and display utilities.
Description COSTAR V, originally developed at the Massachusetts General Hospital and now in the public domain,[1] has been extensively modified by users to fit specific practice needs. Our implementation in the Department of Internal Medicine at the University of Nebraska Medical Center (UNMC) has been no exception, with major changes over the last six years primarily designed to better support what we believe must be an interactive use of computerized medical information. COSTAR was initially designed for implementation on the Digital Equipment Corporation 0195-4210/91/$5.00 C) 1992 AMIA, Inc.
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volume users of COSTAR, our nurses and technicians have been key participants in our users group, constantly offering ideas for developments and novel uses of the computer. The bulk of recent program changes at our institution has focused upon facilitation of interactive ambulatory record keeping using the basic COSTAR data structure. Nursing staff input has been key to the evolution of user friendly data entry features, and improved the quality of record maintenance. Program development tools written in Medical Query Lguage (MQLO) have sped this process, allowing a freer interaction between health care providers and programming staff, thus allowing more rapid change. Past demonstrations [31 have acquainted attendees with interactive exam room developments for COSTAR V. This demonstration will focus on nursing enhancements in use in our clinics which have developed a functional environment for interactive ambulatory nursing management. Clinical features to be presented will include: 1)
2)
3)
4)
5)
nursing case management features- nurse managed care for patients taking oral anticoagulants. Custom features support review of case data, recording of treatment decisions and disposition and communication with the patient.
The majority of these developments employ custom features of MQL, which has been critical for rapid prototyping and development of unique nursing information sets. MQL has been modified to support an interactive environment, and has given us the tools we have needed to support this evolution of nursing information management. COSTAR and MQL are registered trademarks of Massachusetts General Hospital. PDP and VAX are registered trademarks of Digital Equipment Corporation.
[1]Barnett GO. Computer Stored Ambulatory Record. Research Digest Report of the NCHSR: US DHHS Publication HRA 76-3145, National Center for Health Services Research, 1976. [2]Campbell JR, Givner N, Seelig C, Greer A, Patil K, Wigton R, Tape T. Computerized Medical Records and Clinic Function. M.D. Computing. 1989; 6(5):282-287 [3]Campbell JR, Stoupa R. The patient, the provider, the processor: Information management in ambulatory care. Proceedings of the Fourteenth Annual Symposium of Computer Applications in Medical Care: 939-940, 1990. [4]Greenlick MR, et al. Determinants of medical care utilization: The role of the telephone in medical care. Medical Care; 11(2):121-134, 1973. [S]Robert Wood Johnson Foundation. Medical practice in the United States. Princeton, NJ: Robert Wood Johnson Foundation, 1981. [6]Miller E, A conceptual model of the information requirements of nursing organizations. Proceedings of the Thirteenth Annual Symposium of Computer Applications in Medical Care: 784-788, 1989.
nursing encounter data capture- definition of a minimal nursing ambulatory data set by clinic and patient problem. These data are recorded during the intake exam by the nurse in the exam room. rule driven nursing history and managementmedical logic modules (MLM) designed and implemented by a nursing practice committee are the basis for this forward chaining rule system which organizes nursing history taking and assures follow-up on needed nursing interventions. prescription refill functions- includes prescription writing, documentation of patient complaints and drug allergy checking at the time of entry. nursing telephone module- an interactive recording system for management of telephone encounters and facilitation of staff
communication.
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Abstract
The ambulatory office setting is increasingly becoming a central focus of patient care. The nursing staffare integral to patient care management in this environment. They arefrequently the heaviest users of medical records and are generally early advocates of well designed computer records systems. As our implementation of a Computer Stored Ambulatory Record (COSTAR V@) has grown in complexity and utility, reorganization of the record and development of new features to support nursing has become critical. This demonstration will show how nursing information management has changed using a variety of computer record tools, including features of exam room data entry, specialized nursing displays and problem based patient summaries. Specific items for demonstration will include: nursing
check-in module, rule driven nursing history program, prescription refillfunctions, documentation and billingfor nursing procedures, nursing telephone management functions, a modulefor management of anticoagulation and document retrieval and display utilities.
Description COSTAR V, originally developed at the Massachusetts General Hospital and now in the public domain,[1] has been extensively modified by users to fit specific practice needs. Our implementation in the Department of Internal Medicine at the University of Nebraska Medical Center (UNMC) has been no exception, with major changes over the last six years primarily designed to better support what we believe must be an interactive use of computerized medical information. COSTAR was initially designed for implementation on the Digital Equipment Corporation 0195-4210/91/$5.00 C) 1992 AMIA, Inc.
941
volume users of COSTAR, our nurses and technicians have been key participants in our users group, constantly offering ideas for developments and novel uses of the computer. The bulk of recent program changes at our institution has focused upon facilitation of interactive ambulatory record keeping using the basic COSTAR data structure. Nursing staff input has been key to the evolution of user friendly data entry features, and improved the quality of record maintenance. Program development tools written in Medical Query Lguage (MQLO) have sped this process, allowing a freer interaction between health care providers and programming staff, thus allowing more rapid change. Past demonstrations [31 have acquainted attendees with interactive exam room developments for COSTAR V. This demonstration will focus on nursing enhancements in use in our clinics which have developed a functional environment for interactive ambulatory nursing management. Clinical features to be presented will include: 1)
2)
3)
4)
5)
nursing case management features- nurse managed care for patients taking oral anticoagulants. Custom features support review of case data, recording of treatment decisions and disposition and communication with the patient.
The majority of these developments employ custom features of MQL, which has been critical for rapid prototyping and development of unique nursing information sets. MQL has been modified to support an interactive environment, and has given us the tools we have needed to support this evolution of nursing information management. COSTAR and MQL are registered trademarks of Massachusetts General Hospital. PDP and VAX are registered trademarks of Digital Equipment Corporation.
[1]Barnett GO. Computer Stored Ambulatory Record. Research Digest Report of the NCHSR: US DHHS Publication HRA 76-3145, National Center for Health Services Research, 1976. [2]Campbell JR, Givner N, Seelig C, Greer A, Patil K, Wigton R, Tape T. Computerized Medical Records and Clinic Function. M.D. Computing. 1989; 6(5):282-287 [3]Campbell JR, Stoupa R. The patient, the provider, the processor: Information management in ambulatory care. Proceedings of the Fourteenth Annual Symposium of Computer Applications in Medical Care: 939-940, 1990. [4]Greenlick MR, et al. Determinants of medical care utilization: The role of the telephone in medical care. Medical Care; 11(2):121-134, 1973. [S]Robert Wood Johnson Foundation. Medical practice in the United States. Princeton, NJ: Robert Wood Johnson Foundation, 1981. [6]Miller E, A conceptual model of the information requirements of nursing organizations. Proceedings of the Thirteenth Annual Symposium of Computer Applications in Medical Care: 784-788, 1989.
nursing encounter data capture- definition of a minimal nursing ambulatory data set by clinic and patient problem. These data are recorded during the intake exam by the nurse in the exam room. rule driven nursing history and managementmedical logic modules (MLM) designed and implemented by a nursing practice committee are the basis for this forward chaining rule system which organizes nursing history taking and assures follow-up on needed nursing interventions. prescription refill functions- includes prescription writing, documentation of patient complaints and drug allergy checking at the time of entry. nursing telephone module- an interactive recording system for management of telephone encounters and facilitation of staff
communication.
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