Computerized Case History - an Effective Tool for Management of Patients and Clinical Trials

摘要

Monitoring diagnostic procedures, treatment protocols and clinical outcome are key issues in maintaining quality medical care and in evaluating clinical trials. For these purposes, a user-friendly computerized method for monitoring all available information about a patient is needed. Objective To develop a real-time computerized data collection system for verification, analysis and storage of clinical information on an individual patient. Methods Data was integrated on a single time axis with normalized graphics. Laboratory data was set according to standard protocols selected by the user and diagnostic images were integrated as needed The system automatically detects variables that fall outside established limits and violations of protocols, and generates alarm signals. Results. The system provided an effective tool for detection of medical errors, identification of discrepancies between therapeutic and diagnostic procedures, and protocol requirements. Conclusions The computerized case history system allows collection of medical information from multiple sources and builds an integrated presentation of clinical data for analysis of clinical trials and for patient follow-up.