Outpatient medical records for a teaching hospital: beginning the physician-computer dialogue

Abstract

We have developed an outpatient medical record (OMR) system designed to facilitate direct physician interaction with the computer-based medical record. During the first two years the system was in use, staff physicians, residents, and nurse practitioners entered 15,121 active and 1996 inactive problems for 3524 patients, and 12,651 active medications and 1894 discontinued medications for 3430 patients. These clinicians entered 20,321 items on health promotion and disease prevention screening sheets and with the help of automatic updating by the computer an additional 21,897 entries on screening sheets were made for 8686 patients. On the computer, clinicians wrote more than twice as much--10.9 words per problem, in contrast to 4.3 words per problem in the paper record (p less than 0.0001, Student's t). We conclude that clinicians perceived the computer-based problem list to be more valuable than its paper counterpart.