Abstract
The practice of medicine revolves around the collection, interpretation, and dissemination of data about patients. Clinical decisions are based upon information gathered from the patient in light of medical knowledge which has been gained from the physician's experiences while taking care of other patients. The didactic portion of medical education includes the transfer of the profession's cumulative clinical experience to beginners. The products of biomedical research are evaluated by acquiring focused clinical experience through trials of patient care. Payment for health care services, whether by government or third party payors, is obtained by detailed data reporting. The repository of the data associated with these events is the medical chart. Each of the variety of people who use medical data have a unique perspective. A medical administrator's files may appear to contain different data than a physician's, but both of their records will consist of data about patients, their evaluation, and treatment. The focus or emphasis is the only difference. Therefore, to address the diverse requirements of patient care, education, research, resource and financial management, and outside reporting, a computerized medical information system, like the practice of medicine itself, should logically have the working medical record as its centerpiece. A computerized medical information system, The Medical Record (TMR) [1, 2] has been developed at Duke University in Durham, North Carolina, and installed in the nephrology service of the Durham Veteran's Administration Medical Center. TMR focuses on the capture and storage of patient care data, and all other needs, such as accounting, management, and research, are met by programming the computer to interpret or rearrange the data. This paper presents the manner in which the TMR medical record is used in the nephrology service. Note its impact on patient care and clinical research. The difficulties encountered in computerizing medical records will be discussed, and those features of TMR which are essential to its success will be pointed out.
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