Difference between revisions of "Regenstrief Medical Record System (RMRS)"

Revision as of 06:26, 20 September 2009

Orginally developed in 1972 by Clem Mcdonald, Regenstrief Medical Record System (RMRS) is a complex system that involves manipulation, transfer, and storage of data in and associated with electronic medical records. It is the first EMR to generate reminders to physicians about its own content. Using an internally-developed decision support language - CARE, providers could develop protocol-specific reminders to streamline clinical decision making. The goal was to:

(1) eliminate the logistic problems of the paper record by making clinical data immediately available to authorized users wherever they are—no more unavailable orundecipherable clinical records; 
(2) to reduce the work of clinical book keeping required to manage patients—no more missed diagnoses when laboratory evidence shouts its existence,no more forgetting about required preventive care; 
(3) to make the informational ‘gold’ in the medical record accessible to clinical, epidemiologic, outcomes and management research. The system was to complement, not replace, the paper medical record.  

It began in 1972, in a diabetes clinic with only 35 patients. As of 1999, the RMRS carried 200 million separate coded observations,3.25 million narrative reports, 15 million prescriptions and 212,000 electrocardiographic (EKG) tracings. The RMRS carried records for 1.4 million patients in addition to all data generated from several thousand ambulatory and inpatient encounters per year,

As of now, the RMRS is still operating, which carries 660 million distinct observation. This makes RMRS one of the longest operating EMRs in the world. The RMRS is being accessed more than 10 million times every year by Wishard Health Services and 20 million times per year at Clarian Health in Indianapolis.

The RMRS has been best studies and it is well known nationally and internationally to be the model for a number of commercial and academic EMR systems.

This system serves four hospitals on the Indiana University Medical Center campus and forty outreach practices in the city of Indianapolis.

The systems success can be attributed to it's strong foundation in 3 areas.

1. Physician leadership in the informatics effort is vital.  It is their intelligence, self-confidence, high energy, and clinical knowledge.  
2. Commitment to the mission and vision of high quality and excellence in health care driven and believed in from the highest echelon within the hospital, and 
3. Continuous quality improvement and incorporation of user feedback to guide this improvement.  Quickly fixed mistakes are tolerated by Physicians, and this had driven an evolutionary approach.  The software is updated incrementally and feedback from the users is sought early and often.  Feature's are added based upon which is easiest to fix or implement.  

The data repository is the key component of the system. It originally called for no data entry for physicians' observations. Creator Clement McDonald, M.D. and his co-authors note that physicians were reluctant to perform data entry. The system developers first enlisted physicians for data entry with a physician orders system because orders are more easily structured for data input than observations.

Today, most nursing home orders, as well as ED release and inpatient orders are entered directly into the computer system by physicians using the Medical Gopher CPOE workstation. Dictated discharge summaries have largely been replaced by physician-generated discharge notes entered directly into the computer. Similarly, most of the outpatient clinic notes are entered directly into the computer using the Medical Gopher system.

The Gopher workstation also allows the printing of personalized patient information handouts, permits doctors and nurses to communicate via confidential email and can even display satellite weather photos. Physicians can also access past issues of leading medical journals and the American Hospital Formulary drug monographs to research specific topics or learn more about a certain medication.

A 2001 study from Wishard Memorial Hospital demonstrated that computerized reminders significantly improved the use of preventative measures in eligible patients admitted to the hospital. Compared to a control group, those patients whose physicians received reminders received more influenza and pneumococcal vaccinations, subcutaneous heparin prophylaxis and aspirin at the time of discharge. However, even with the reminders, compliance with the recommendations was still far from being universally accepted by the physicians.

One of the keys behind the system is that the numerous forms and reports are not pre-generated. Instead, they have a generalized template ("schema") which deals with high-level components like "notes in this section" and "vitals in this section". And then based upon the data for a patient, the display is materialized.

The general layout of the system is with the problem list on the upper left side with a physician specified and chosen set of observation variables like vitals on the lower left portion of the screen. On the right side is a section for notes and below that is where orders are entered and reviewed. As far as reports, a great deal of them can be created and customized to the encounter. Such reports can be as wordy or succinct as the doctor desires and ready prior to the patient encounter.

References

The Three-Legged Stool: Regenstrief Institute for Health Care. Clement McDonald, M.D.

Indiana School of Medicine

RMRS Introduction

McDonald CJ. The Regenstrief Medical Record System: a quarter century experience. International Journal of Medical Informatics. 1999. 54(1999)225-53.

Dexter PR, et al. A Computerized Reminder System to Increase The Use of Preventative Care for Hospitalized Patients. NEJM 2001; 345 (13):965-70.

Friedlin J., et al. Details of a Successful Clinical Decision Support System. AMIA Annu Symp Proc 2007; 2007:254-258.