The Electronic Medical Record: Medical Records That Teach Communication Skills

Abstract

In 1985 we began developing a hospital information system (HIS) at the Veterinary Medical Teaching Hospital (VMTH) at University of California, Davis. We wanted to provide easy and timely access to medical, surgical, laboratory, radiographic, demographic, and financial information in a patient-oriented, integrated format. In the course of its development, the HIS expanded to include pharmaceutical and supply information as well as images, clinic schedules, and evaluations. The HIS has become a management tool for hospital services such as pharmacy and central supply and a support tool for administrative functions, including clinical service schedules and performance evaluations of students and residents. The HIS is now a comprehensive computerbased system that provides the information we use to care for patients; teach students and residents and evaluate their skills, knowledge, and professional attributes; perform clinical research; support continuing education and service to the community; and administer the hospital. The core of the HIS is the patient-oriented electronic medical record (EMR). Besides serving the traditional function of the patient record as a repository for all-important patient information, the EMR is now a primary tool for teaching critical thinking and communication skills to students and residents. Evoking the vision of Lawrence Weed, it has become a medical record that teaches.