Electronic medical records optimize clinical data management in the outpatient cardiological clinic

摘要

A system based on a relational database with administrative and clinical information and integrated with an information system, where the system covers the role of a functional island, is routinely used in our Institution. To analyze how electronic medical records (EMR) may help physicians in organizing and reducing time waste in a busy outpatient clinic, a sample of 1000 reports were evaluated for system performance. The time needed for building new clinical histories or modifying the already acquired ones, to create physical examination and biochemical and instrumental exams reports, was assessed. Cardio-pulmonary tests, basal, dynamic and effort EKG, chest X-ray, echo Doppler studies, nuclear medicine procedures, invasive techniques, were collected. Clinical management was integrated with the administrative system (ADT), to correctly identify each patient. This system provided not only easy retrieving of stored data such as clinical history, physical examination, instrumental exams reports but also the results of new exams performed in the same day of patient visit with a time lapse of 1 to 20'. Graphical interface structure contained preformatted fields which allowed selection or modifications of data/text models without additional waste of time. EMR represents an important tool for organization and synergy of different laboratories in an outpatient clinic, optimizing the time needed for data entry and leading to an overall better quality of care.