Larry Lemmon

The Regenstrief Medical Record System: a quarter century experience

Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology.

Data base management, feedback control, and the Regenstrief Medical Record.

Because of the differences in informational needs among medical practices, medical record systems should be fiexible. The use of data base management and use-oriented command languages helps to achieve flexibility. The Regenstrief Medical Record System is based upon a data base management system and two user-oriented command languages (the RDB Command Language and CARE). Most batch reports, file maintenance procedures, and ad hoc retrievals can be specified by the user by means of these two languages. This means that the user can specify which reports he wants and how they should look. Daily on-line activities are performed by application programs. The data base system also provides flexibility to these programs since the content and format of many of the display screens are defined by statements that are similar to the command language statements and are stored within a text file. The Regenstrief Medical Record System now carries records for 60,000 patients.

Use of a Regional Health Information Exchange to Detect Crossover of Patients with MRSA between Urban Hospitals

BACKGROUND A significant portion of patients already known to be colonized or infected with Methicillin-Resistant Staphylococcus aureus (MRSA) may not be identified at admission by neighboring hospitals. METHODS We utilized data from a Regional Health Information Exchange to assess the frequency that patients known to have MRSA at one healthcare system are admitted to a neighboring healthcare system unaware of their MRSA status. We conducted a retrospective, registry trial from January 1999 through January 2006 involving three healthcare systems in central Indianapolis, representing six hospitals. RESULTS Over one year, 286 unique patients generated 587 admissions accounting for 4,335 inpatient days where the receiving hospital was not aware of the prior history of MRSA. The patients accounted for an additional 10% of MRSA admissions received by study hospitals over one year and over 3,600 inpatient days without contact isolation. CONCLUSIONS Information exchange could improve timely identification of known MRSA patients within an urban setting.

A regional informatics platform for coordinated antibiotic-resistant infection tracking, alerting, and prevention

BACKGROUND We developed and assessed the impact of a patient registry and electronic admission notification system relating to regional antimicrobial resistance (AMR) on regional AMR infection rates over time. We conducted an observational cohort study of all patients identified as infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) on at least 1 occasion by any of 5 healthcare systems between 2003 and 2010. The 5 healthcare systems included 17 hospitals and associated clinics in the Indianapolis, Indiana, region. METHODS We developed and standardized a registry of MRSA and VRE patients and created Web forms that infection preventionists (IPs) used to maintain the lists. We sent e-mail alerts to IPs whenever a patient previously infected or colonized with MRSA or VRE registered for admission to a study hospital from June 2007 through June 2010. RESULTS Over a 3-year period, we delivered 12 748 e-mail alerts on 6270 unique patients to 24 IPs covering 17 hospitals. One in 5 (22%-23%) of all admission alerts was based on data from a healthcare system that was different from the admitting hospital; a few hospitals accounted for most of this crossover among facilities and systems. CONCLUSIONS Regional patient registries identify an important patient cohort with relevant prior antibiotic-resistant infection data from different healthcare institutions. Regional registries can identify trends and interinstitutional movement not otherwise apparent from single institution data. Importantly, electronic alerts can notify of the need to isolate early and to institute other measures to prevent transmission.

Nascent Regional System for Alerting Infection Preventionists about Patients with Multidrug-Resistant Gram-Negative Bacteria: Implementation and Initial Results

OBJECTIVE To build and to begin evaluating a regional automated system to notify infection preventionists (IPs) when a patient with a history of gram-negative rod multidrug-resistant organism (GNRMDRO) is admitted to an emergency department (ED) or inpatient setting. DESIGN Observational, retrospective study. SETTING Twenty-seven hospitals, mostly in the Indianapolis metropolitan area, in a health information exchange (HIE). PATIENTS During testing of the new system: 80,180 patients with microbiology cultures between October 1, 2013, and December 31, 2013; 573 had a GNRMDRO. METHODS/INTERVENTION: A Health Level Seven (HL7) data feed from the HIE was obtained, corrected, enhanced, and used for decision support (secure e-mail notification to the IPs). Retrospective analysis of patients with microbiology data (October 1, 2013, through December 31, 2013) and subsequent healthcare encounters (through February 6, 2014). RESULTS The 573 patients (median age, 66 years; 68% women) had extended-spectrum β-lactamase-producing Enterobacteriaceae (78%), carbapenem-resistant Enterobacteriaceae (7%), Pseudomonas aeruginosa (9%), Acinetobacter baumannii (3%), or other GNR (3%). Body sources were urine (68%), sputum/trachea/bronchoalveolar lavage (13%), wound/skin (6%), blood (6%), or other/unidentified (7%). Between October 1, 2013, and February 6, 2014, 252 (44%) of 573 had an ED or inpatient encounter after the GNRMDRO culture, 47 (19% of 252) at an institution different from where the culture was drawn. During the first 7 weeks of actual alerts (January 29, 2014, through March 19, 2014), alerts were generated regarding 67 patients (19 of 67 admitted elsewhere from where the culture was drawn). CONCLUSIONS It proved challenging but ultimately feasible to create a regional microbiology-based alert system. Even in a few months, we observed substantial crossover between institutions. This system, if it contributes to timely isolation, may help reduce the spread of GNRMDROs.

The regenstrief clinical laboratory system

The Regenstrief Clinical Laboratory System (RCLS) has been operational since 1975 at Wishard Memorial Hospital in Indianapolis, Indiana (a 580 bed facility). The clinician support, user interfaces, and use of a true data base management system distinguish this system from many commercially avaiIabIe laboratory systems. Physician reports include laboratory, clinic, pharmacy and radiology data in a single, compact flow sheet. The system can search patient medical records for conditions that may require corrective action and inform physicians of the reasons these actions should be considered. The site-specific modifications required to transport this system do not require re-programming. The system allows multiple specimen numbering sequences; identification of terms by name or number; unlimited amounts of free text; reports that can be tailored by non-programmer personnel; CAP accounting statistics; on-line instrument interfaces; and extensive on-line instructional facilities. The Regenstrief Clinical Laboratory System (RCLS) accomplishes most of the data capture, reporting and management functions expected of such systems, but it has a number of distinguishing features. These include: 1) its focus on usage by the clinician; 2) its accomodating user interface; 3) its roots in a true data base management system.