A Computerized
Recall
System
for Office
Practice
D. Leduc,
MD, H. Loeser,
MD, L. Hercz,
MEng,
and I. B. Pless,
MD
From the Department of Pediatrics and Community Pediatric Research, McGill-Montreal
Children ‘s Hospital Research Institute, Montreal
ABSTRACT. A computerized system that has been in use
in a small group practice since 1980 is described. Although many pediatricians have begun to use personal computers in office practice, most accounts of their experience to date relate primarily to the role of computers in facilitat-ing administrative tasks, such as billing. The procedures
involved in establishing the system are described, along
with details about the nature of the programming con-cepts and several of the most important applications. A particular focus was to enable the computer to be used to improve the follow-up ofpatients with problems requiring recall visits, eg, immunizations. The results indicate that the percent of patients judged to be overdue for
immu-nizations fell from 15.4% prior to the introduction of the computer to 1.3% and 4.3%, respectively, in the following
2 years. The proportion of children with other health
problems requiring follow-up, 44.5% of the entire active practice population are also described. It is concluded that the computerized system can enhance the quality of patient care and greatly facilitate office-based research.
Pediatrics 1984;73:233-237; computer uses, data manage-ment, patient follow-up, research in practice.
By far the most widely applied, thoroughly de-scribed,”2 and generally accepted use for computers in private practice is to facilitate administrative tasks, eg, billing, accounting, appointment-making,
and inventory. Although personal computers are becoming increasingly popular as a efficient way to deal with these chores, there is, however, another important role for computers in practice: improving
Received for publication Jan 21, 1983; accepted April 28, 1983. The assumptions, decisions, and conclusions in this article are
those of the authors and do not necessarily represent the views
of the Charles E. Merrill Trust or the Robert Wood Johnson
Foundation.
Reprint requests to (D.L.) Department of Pediatrics and Com-munity Pediatric Research, McGill-Montreal Children’s Hospi-tal Research Institute, Montreal, Quebec H3H 1P3, Canada. PEDIATRICS (ISSN 0031 4005). Copyright © 1984 by the
American Academy of Pediatrics.
patient care and facilitating research. Unfortu-nately, few practitioners have a system that permits
them to retrieve any portion of patients’ records rapidly and efficiently. The cumbersome and time-consuming chart review is still the method most used by doctors.
To overcome this, some physicians compile lists of various conditions or special disorders requiring periodic monitoring. McBee file cards or diagnostic and age-sex registers (such as the E-book) are good examples of this approach.3 The problem-oriented record, initiated by Weed,4 has also been accepted by some as a means of organizing the medical chart itself for easier access to problems. All of these methods, however, require a commitment from of-fice staff to keep the information up to date. This, in turn, means increased costs and secretarial time. In light of the limited success of these efforts, a system designed to improve .the surveillance and
management of patients with complex problems has
advantages that merit further attention. Despite medicine’s usual alacrity in embracing technologic
advances, many practitioners have resisted using one of the most effective and efficient information systems now available, the computer.
The present report describes the application of computer principles in a pediatric group practice. The term “computer” in this context usually refers to those classified as “personal” (eg, Apple II, TRS, etc) and is used interchangeably with “microcom-puter.” However, the computer actually used was a hospital-based Hewlett-Packard 3000 (a mini- or medium-sized mainframe system) to which the
practice was linked through a terminal.
Computer describe how this maneuver improved knowledge
about the practice, and the services provided, through an easily retrievable patient profile. Tm-proving the status of those who are poorly immu-nized, or who need more continuity in their health care, was of particular interest. A final objective was to organize a data bank to facilitate clinical research.
METHODS
Chart
Review
The first step was the development of a comput-erized file for all patients in the practice. A sys-tematic review of every medical chart, using a spe-cially designed abstact form, generated a complete
list of patients along with basic demographic and clinical data. The information included in the ab-stract was a product of the pediatricians’ consensus about the information needed and that which is consistently available in the chart. Selection was also influenced by the system designer’s opinion of the computer’s capabilities.
Individual consent from parents was not required because access to the file was carefully protected by passwords, and none of the information on the computer file was of a sensitive nature.
Demographic data included: name, birthdate, sex, telephone number, and the identity of the primary pediatrician. Clinical data included an assessment of immunization status, made by comparing the child’s age and immunizations with American Academy of Pediatrics criteria.5 A recall date 2 months later than the date for the next required immunization was entered. Mumps and rubella were assessed separately from measles, thus per-mitting elective postponement of these immuniza-tions to adolescence.
Risk factors and clinical problem data were then assigned to selected patients, based on the antici-pated need for documenting or monitoring the ev-olution of medical or social problems. The cate-gories of problems so closely resembled the table of contents of NeLson Textbook of Pediatrics6 that these organizational divisions were adopted. This provided a clearly defined reference system for use when newly encountered problems had to be cate-gorized.
For example, anemia was categorized under “blood.” If it required follow-up, a recall date was assigned. As in the case of immunizations, this was the latest date by which the patient should be seen again for assessment. Conversely, neonatal as-phyxia (categorized under “neonatal”), if no longer requiring recall, remained in the computer file as a problem, but no date was assigned.
Instead of a personal computer as such, the office uses an interactive video terminal with a typewriter keyboard linked to the computing center at the hospital. This is done by an acoustic coupler that accepts a regular telephone receiver and uses exist-ing telephone lines. A program specifically designed to meet the stated objectives was used to enter all abstracted records on the hospital’s Hewlett-Pack-ard 3000 computer.7
Beyond typing skills, no specialized knowledge is required by the person working at the terminal. The computer commands are simple and are dis-played on the screen as conventional English words. They help the user to perform a variety of steps with the “prompt” words shown in capitals: to ENTER information about a new patient; to
UP-DATE an existing file by changing current or
add-ing new information; to FIND and DISPLAY any information on a specific patient record; to DE-LETE files of patients who leave the practice; and to QUERY the patient file through a SEARCH to find all patients with certain characteristics.
Once a new patient’s data were entered, changes reflecting any pertinent additional information were continually incorporated into the file. This was achieved by listing all items to be altered on a slip attached to the chart. On the cathode ray tube (CRT) screen, the secretary then periodically re-called and updated files needing changes. This re-quired approximately one hour per week.
The program enables the computer to identify all patients who are overdue for any reason, eg, im-munizations or follow-up examinations. The names of these patients can be displayed on the terminal or listed as printed copy. The user can also rapidly find groups of patients with any combination of the following: sex, year of birth, telephone number, pediatrician, diagnosis (up to five problems), and immunization status.
RESULTS
Time and Costs
Over a 2-month period the required information
was transferred from all charts to abstract forms. Each abstract was then reviewed by the child’s
physician and subsequently scanned for complete-ness and consistency. A total of 300 hours of per-sonnel time was needed to prepare and enter these data.
proc-TABLE 2. Practice Profile and Characteristics of Chil-dren “at Risk”
sex are listed in Table 2. Our ability to observe
essing is less than $2,000 per year, or approximately 50 cents per patient per year.
Practice Profile
Of
the 2,600 charts reviewed, 416 were considered inactive. Of these, 386 patients either had not been seen in more than 2 years and could not be con-tracted, or were known to have moved or changed to another practice. Thirty patients could not be located. Over the first study year (1979-1980) an-other 400 patients were deleted from the practice (using the criteria described above), and nearly 1,500 new patients were added. Two years later (1982), an additional 900 patients were registered, whereas 781 were deleted.From its inception, this system has benefitted the practice in three ways: (1) by facilitating health maintenance, (2) by improving surveillance, and (3) by facilitating research.
Health
Maintenance-Immunizations
At the beginning of the study year, 1,762 patients
(80.7%) were up to date and 422 (19.3%) were considered overdue for primary immunizations (Ta-ble 1). One year later there was a marked improve-ment: only 41 (1.3%) of the active patients were overdue, ie, 98.7% were fully up to date. This trend was sustained to 1982 when 96.4% of the active patients were fully immunized. Analysis of the ac-tive patients in the practice is shown in Table 1. If the nearly 1,200 patients deleted since 1979 are included, and an “overdue” label is assigned to all patients whose immunization status was unknown at the time of discharge from the practice, the overall completed immunization rate would still have increased more than 30% since the outset.
Surveillance
Of the active patients whose records were origi-nally entered in the computer, 886 (40%) had at least one risk factor or problem that needed close surveillance. This proportion has remained rela-tively constant during the past 3 years. The types
of
problems currently being monitored, their fre-quency, and their distribution according to age andTABLE 1. Immunization Status
1979 (Before Computer)
1980 1982
Up to date 1,762 3,191 3,587
(84.6%) (98.7%) (96.4%)
Overdue 336
(15.4%)
41 (1.3%)
161 (4.3%)
Total 2,098 3,232 3,748
x2
P<.OO1 Pcz.0O1n %of %of”at
Total Risk” Practice Group
n = 3,748 n = 1,675 Age (yr)
<2 1,512 40.3 8.2
2-5 1,166 31.2 42.9
6-14 754 20.1 43.2
>14 316 8.4 5.6
Sex
M 2,010 53.6 54.7
F 1,738 46.4 45.3
Problem titles
Allergy/asthma 316 8.4 18.8
Social/develop- 253 6.8 15.1
mental
Neonatal 249 6.6 14.9
Respiratory/ENT 226 6.0 13.5 (ear, nose, and
throat)
CNS disorders 151 4.0 9.0
Nephrology/urol- 105 2.8 6.3 ogy
Digestive/nutri- 106 2.8 6.3
tional
Bones and joints 65 1.7 3.9
Blood 49 1.3 2.9
Cardiovascular 42 1.1 2.5
Miscellaneous 113 3.0 6.8
these patients closely and to maximize surveillance
measures is, therefore, greatly enhanced by the information generated from this retrieval system. For example, in the care of children with asthma, pulmonary function studies are one of the periodic evaluations that can be used to follow the status of
airway disease and response to therapy. Also, the-ophylline blood levels, or at least periodic drug dosage adjustments and monitoring, need to be performed regularly. By “tagging” these procedures with a recall date for that problem, the computer is able to feed this information back at our request, thereby avoiding delays in follow-up. In the area of prevention, influenza vaccine is given to all patients with moderate-to-severe asthma who are more than 3 years of age; therefore each autumn, when these patients need to be contacted, the computer pro-vides a list of all patients in the practice who are older than 3 years and who have asthma listed as a “problem.”
Research
In an excellent review of research in pediatric
on one’s own situation, one’s own backyard is the best place to start.” Indeed, the ability to generalize conclusions drawn from ambulatory pediatric re-search in a hospital setting is often hampered by the issue of relevance to private practice. Inasmuch as one of the many difficulties encountered in an office research setting is identifying and finding the population under study, this computer system can overcome these pitfalls by providing rapid retrieval of groups of patients with specific diagnoses and selected demographic data. Several types of studies are now in progress. These include mostly descrip-tive research; nonetheless, the methodology in-volved in “intervention” studies is also facilitated because experimental and control groups can be labeled as such for entry into the computer and then retrieved selectively for chart review when the data are ready for analysis. For example, a list of all 6-year-old girls in the practice who had a learn-ing problem and a complicated neonatal course was obtained in less than one minute. Similarly, a list was generated of all children between the ages of 3 and 5 years who had a history of recurrent ear infections. At the time of this study, these patients were being followed up longitudinally for speech and hearing along with matched control subjects also obtained from the computer file.
Technical Considerations
Although personal computers are attractive and could be used with a program such as that described,
no
“software” is currently available on a commer-cial basis. Thus, the potential user would need to write his or her own programs or attempt to adapt the one written for this project.Many personal computers equipped with flexible storage devices (diskettes or floppy disks) will not satisfy the needs of a private practice wishing to use their system to recall patients. A single diskette cannot contain the information on all patients in a practice; speed of information retrieval from a dis-kette is slow, and if diskettes need to be switched in the process, it becomes awkward.
There are two newly available technologic devel-opments that should make it feasible to have a truly functional, free-standing system in an office. The first is the availability of reasonably priced metallic hard-disk storage devices (“Winchester” drives). These units are more reliable, and access speed is significantly faster. A single unit allows at least 5 to 10 million characters of information to be stored as compared with the 250,000 on a diskette.
The second development is the appearance of advanced-file management software. Even hard-disk drives are too slow to scan records sequentially until a desired file is reached. This operation can
be speeded up by creating an index, similar to a
telephone book. This allows access to a patient’s
record directly by name, chart number, or by
med-ical problem, etc. The setting up of these indexes is
facilitated by file management software but is only feasible on hard-disc drives with their fast access and large storage capacity. File data management
(or
the more sophisticated data base management) software is complex, requires a long time to develop, and must be reliable.These more advanced systems will cost close to $10,000, in contrast to the $3,000 personal
com-puters of today. However, even these will not allow multiple terminals, eg, one for the receptionist and one for the physician. On the other hand, all of these features-multiple terminals, extended
stor-age, fast access, and data base management
soft-ware-are available if terminals connected to a
larger computer at a service bureau, such as the arrangement described in this paper with the hos-pital-based computer, are used. On such shared computers, each user’s information is password pro-tected and not accessible to other users. Added advantages are professional programmer support,
to
facilitate changes in software.DISCUSSION
There is scant evidence to document the intuitive assumption that improved systems of information organization and follow-up do actually improve pa-tient care. Barnett et a19 demonstrated that quality
of
patient care improves when relevant information is rapidly and repeatedly fed back to the provider. Their data also show that nearly half of the im-provement is actually Iue to improved record-keep-ing.Subsequently, Froom1#{176} demonstrated the in-creased clinical productivity of the process of re-viewing charts in order to create problem lists. Practical examples facilitated by the resulting im-proved data systems include: a selective influenza immunization program for all patients with certain predisposing characteristics; a diet workshop to which all obese patients were invited; and a screen-ing program for lead level for those living in re-cently designated high-risk areas.”
Many large, often university-based, ambulatory care groups have replaced the traditional hand-written medical record with one that is elicited, generated, and stored by computer.’2”3 A recent article describes the use of microcomputers in a division of general pediatrics for statistics, mailing
to systems that exist in situ.15”6 This report,
how-ever, describes a low-cost and generally feasible
alternative: the use of an office terminal linked to
a central (hospital-based) computer by a standard
telephone line. As a consequence of this
arrange-ment, the link between the hospital and the
prac-titioner in the community has been greatly strengthened. In time, this should lead to the de-velopment of a more cooperative approach between departments of pediatrics, their hospital facilities,
and community physicians to the delivery of health
care, to training, and to the conduct of research.
We view this as a harbinger of the 80s, a period
during which “town-gown” differences should di-minish. The well-established networks that now link this practice to the human and technical re-sources of the hospital should serve as an example
of
this principle. It merits the attention and support of the department chairman, practitioners, and those in community health deparlments.In summary, rapid technologic advances in
com-puter science will continue to provide increasing sophistication to the design of programs for the storage and retrieval of patient information. Al-though one of the main objectives in the design of this particular system was to provide a continuously updated list of “problem” or “at risk” children, the most difficult tasks are to locate these patients and
have them keep their appointments. Several
re-minders are often necessary, and a home visit by a health nurse may even be required. This additional burden on the secretarial staff may not be accept-able to many and may be frustrating to most unless links with community resources have been well established. Despite these problems, this vastly im-proved information system should result in better health care for those patients who need it most.
ACKNOWLEDGMENTS
This study was supported, in part, by the Charles E.
Merrill Trust. Dr Loeser was a Robert Wood Johnson
Clinical Scholar during the study period.
Without the participation and cooperation of Drs Na-omi Stein and Mary Gillin, the project would not exist.
We also acknowledge the research and clerical support of
C. Brodhead, L. Gibbons, R. Drummond, I. Zvagulis, and
S. Nebesky Whyte, and the counsel of Dr Carol Mozes.
REFERENCES
1. Benininger B, Peart AFW: Present status of
microcompu-ters in medical practice and health care. Ann R Coil Physi-cians Surgeons Can 1980;13:317
2. Cahn M: The physician’s primer to purchasing a
comput-erized medical business system. Comput Med 1979;8:6
3. Pritchard P (ed): Manual of Primary Health Care. London, Oxford University Press, 1978, pp 139-140
4. Weed LL: Medical Records, Medical Education and Patient Care. Cleveland, The Press of Case Western Reserve
Uni-versity, 1969
5. Report of the Committee on Infectious Diseases: The 1982 Red Book, ed 19. Evanston, IL, American Academy of Pe-diatrics, 1982
6. Vaughan VC III, McKay RI Jr, Behrman RE (eds): Nelson Textbook of Pediatrics, ed 11. Philadelphia, WB Saunders
Co, 1979
7. Hercz L, Leduc D, Loeser H, et al: Patient follow up system for a pediatric practice, in O’Neill JT (ed): Proceedings of the Fourth Annual Symposium on Computer Applications in Medical Care. Washington, DC, IEEE Computer Society
Publications, 1980, p 800
8. Nazarian LF: Research in pediatric practice. Pediatr Clin North Am 1981;28:585
9. Barnett GO, et al: Quality assurance through automated monitoring and concurrent feedback using a computer-based
medical information system. Med Care 1978;16:962
10. Froom J: Conversion to problem-oriented records in an
established practice. Ann Intern Med 1973;78:254 11. Henk M, Froom J: Outreach by primary-care physicians.
JAMA 1975;233:256
12. Zimmerman J, Rector A: Computers for the Physician’s Office. Portland, OR, Research Studies Press, 1978 13. Barnett GO: Computers-Stored Ambulatory Record
(COS-TAR). NCHSR Research Digest Series. US Dept of Health, Education, and Welfare Publication HRA 76-3145 (NTIS
#PB 248314). Rockville, MD, Government Printing Office, 1976
14. Schwartz W, Hammer L: Use of microcomputers in the
division of general pediatrics. Pediatrics 1983;71:328
15. Trobridge GF: Use of a microcomputer in a three-physician practice. Can Med Assoc J 1978;119:811
