The Regenstrief Medical Record System: a quarter century experience

Entrusted with the records for more than 1.5 million patients, the Regenstr ief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana Universi ty Medical Center campus and more than 30 Indianapolis clinics. The RMRS ro utinely captures laboratory results, narrative reports. orders, medications . radiology reports. registration information: nursing assessments, vital s igns, EKGs and other clinical data. In this paper, we describe the RMRS dat a model, file structures and architecture, as well as recent necessary chan ges to these as we coordinate a collaborative effort among all major Indian apolis hospital systems. improving patient care by capturing city-wide labo ratory and encounter data. We believe that our success represents persisten t efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOI NC, and DICOM. Inpatient and outpatient order entry systems. instruments fo r visit notes and on-line questionnaires that replace hardcopy forms, and i ntelligent use of coded data entry supplement the RMRS. Physicians happily enter orders. problems, allergies, visit notes, and discharge summaries int o our locally! developed Gopher order entry system, as we provide them with convenient output forms. choice lists, defaults, templates. reminders. dru g interaction information. charge information, and on-line articles and tex tbooks. To prepare for the future. we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employi ng wireless technology. (C) 1999 Elsevier Science Ireland Ltd. All rights r eserved.