IMR-Entry (Intelligent Medical Record-Entry) Frank Naeymi-Rad Ph.D.1, Fabio deSouza Almeida, M.D.2, and David Trace, M.D.1 lUniversity of Health Sciences/The Chicago Medical School, North Chicago, Illinois 60064 2University of California San Francisco, San Francisco General Hospital, Santa Clara, California 95051 IMR-Entry (Intelligent Medical Record-Entry) is a knowledge-based program of medical terminology organized into a structured format to allow ease of access and to expedite entry. IMR-E provides user-friendly entry procedures which allow the user to take maximum advantage of its comprehensive knowledge-base. IMR-E is not simply a database of terminology. It can generate reports in a standardized format from the data entered and then allows the physician to edit these reports as needed. IMR-E is flexible. The knowledge-base can be updated or modified using our authoring tools, which require limited computer expertise. Any additions or modifications to the terminology database are incorporated into the reports. The most noticeable characteristic of IMR-E is its ease of use through a graphical user-interface (GUI). Icons guide the user through the different stages of entry. On-line help is available to simplify navigation through the system. These utilities ensure that the user is never "lost" or disoriented within the program. The entry system is organized in a logical hierarchy of detail, starting from the broad characteristics of the patient and then working down to the meticulous details of any symptom. Hence, comprehensiveness is not sacrificed for ease of use. IMR-E is designed to functionally operate independent of any other system. Yet, linkage has been developed in order to communicate with MEDAS (Medical Emergency Decision Assistance System). IMR-E is flexible enough to link with many other contemporary medical software packages such as: Iliad, QMR, and DXplain. We will demonstrate the progrmun's major components including: The entry system, client server model, knowledge management, and IMR-E's interface to the MEDAS. We will demonstrate the system running under Apple Macintosh (Powerbook 170), Microsoft Windows 3.1 and NCR pen systems. IMR-Entry requires providers to identify themselves before they are allowed to use the system. This identification is used to tag all of the data created for the given session by the entry person. This process insures the data stored on the client system is only accessible by the authorized provider. The following screen demonstrates the main menu screen for IMR-E.
PATS.'
WIOAT
C
Clt 1AW
*
pm-
As you can see, this menu is comprehensive and covers all of the sections of a typical history and physical. The navigational icons were designed to aid the physician at each step of entry. For example, clicking the chief complaint icon brings up the following screen: - --
II
emal EMPIebts
I
1--
--- ---- --- -
:1 F
--
-
..
,I,,
aheammlmal pain eMememnl dklelsmal Zlb
1ebarues
Sheewedsomiriu
_1~
lack paln
leo mettie Iljak@g *bems video
,I Pale)
There are 105 complete programs in IMR-E V1.0. Each chief complaint module allows the physician to create a paragraph customized for a given patient by using the mouse. Each program manages between 20 to 50 objects, which are displayed on 3 to 5 screens. The following is the first screen for the Abdominal Pain Chief Complaint. We can select the appropriate options by simply clicking on them, except that the number 12 must be typed or written with a pen. fIIemins 'aSi n
gattea---
nsl -'Draltio"~
a
iute1
IZ
Immimail variable
mineutes
irmit
dogs
eioi
Weeks
months
medllaleion
Leotlii
eourse decreasing
right upper quadrant left upper quadrant
recurrent
pariumbelical ar
constant
epigastrhu.m
left
783
WMATRT
IV
_UMBU&M
0195-4210/92/$5.00 © 1993 AMIA, Inc.
S
AUmOITAX L COWLAU
II MEW MOR
-
MI
aowe quadrant
left sheidder
back &
n right flank
*
Ielpigastrium right upper quadrant adrea
1A'
. |;~ I
The following is an exanple of a History Screen. By selecting the HISTORY folder we can enter all of the history information.
LnntQa.Pm. kI .P.Afl1taI 9 db. .9. .0.gy.......r. .......... Q,1 .S±^.t. 1 J n.L@fl..... OPa&1J P.PW.fi.d.-mimi X.4QD. QQ1C.1L. +..Waf4Qnttni.nz.lonLLQonAablJ.QwtprsuoAwiiL... CC I fl1 ~ ~ ~ ~ Q .Qmcm0anA ..
CC.1 eI tA.tmInj.penflgpAac L4tb.§y
eTm
Anhwtheri.zedwt ebinb..... C .1... C.HZ±+.A Q;nci.n 6L :CC. 1 .CH3±LabNmy)yJl.an chorterizcd as stabbinj CC. 1 3AS18 +±ardwi.onwsuarPsocm edrWithtevor ....... 4i nki alpan .soc.mted.'.wtt.h.s.aujet ,C.C 1.A.S 1 L9t|.a.P,.. ,MEDS *97 t.fBEN*2AI.THI!NE P..EIJqC.1LIJN G A9 7.............. ,PMHCY 38 .. Cerdio%ecuIer PulmonwyHypertension C.... l. .8...+..ap...... . .nd .u... .a. . a...t.e. . ..pw.....
i i 5
Naeymi-Aed. Frank
1i/10/5s 1111443333 Daue Trace
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....... A.... . .... ........ ... ..... .... ............ . . ..... ....... ..
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.
...
.
.... .......... ......... ....... ... ...........
UL
The next screen is the result of clicking on the Physical Exam icon from the main menu: Reset
Physical Exam Nm
m m
i own"
MmmdNO..S No
M
M
a
Ew* E_ Em-ir
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Eme tSd
tS3
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as bomd
20 O r
0o I
E's EtSti@O D
13
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There are three options for each selection: Normal, Normal Except, and Not Examined. Not Examined will print "not examined" on the report. The Normal option will automatically print the user's custom designed normal exam on the report. The next screen demonstrates an example of the Palpation/Percussion screen. leset
I I
patient-specific termns
oal
a_ ReAound toodemuess Rigidity Iguarding$ Liuer paipable Spleen paipable Rbdominal mast paipablo
The patient Is a 41 gear aId married whiie male with __81NKK19 who presents Luith complaints of abdominal pain. The onset o1 the abdominal pain has been suddNs and has been occurring for 12 hours. The pattern of the abdominal pain has been persistent. It's course has been Increasing. The abdominal poln is loeated In the right lower quadrant with radiation to the left flank end left lower quadrant. 11 is aggravated bg coughing, standing end walking while relief is obtained bg nothing. Th& abdominal pain Is characterized as sharp and stabblnq. The
A list of
i.......
D... ....................
Clicking the text icon displays the current status of the electronic report that has been compiled in the background throughout the dhata entry process. I
an
H.ad.. CC .CI.C 1.a^ RE A..+... a.P.§qi.. . .4.. n..a. ml.A.tQ. XQA . o .t...i....... .... IJ..... ha-r. P.. .. .... 1+±L4Lr'S...
By selecting the PAST MEDICAL HISTORY Folder we get to the next screen. I
.
.
LL
OsCI esteY
.
.
HISThEY
T
t2 .4iP9fl.QM............... ................ d.Zino.h9.Mm
.c P.a^|. ttQWj
a
Dullness to percussion Tgmpanhc to percussion Shifting dullness Fluid woue Ubturatar sign Psoes
r--.
NS3I
Absent
Senenil ls |"lc
'Pt
r~ quadranti
sign
quit
is also
generated
in the
background during data entry. These terms can then be sent to expert systems for consultatiions, quality assurance systems, and literature retrieval systems. IMR-E currently generates 165,000 tenns.
We present a user-friendly, comprehensive, computerbased patient record (CPR) that can handshake with medical expert systems. Pilot studies with IMR-E have generated substantial enthusiasm. We plan to connect IMR-E to existing drug interaction progruams and billing programs in an effort to establish the initial components of a physician's clinical workstation.
784
PATS.'
WIOAT
C
Clt 1AW
*
pm-
As you can see, this menu is comprehensive and covers all of the sections of a typical history and physical. The navigational icons were designed to aid the physician at each step of entry. For example, clicking the chief complaint icon brings up the following screen: - --
II
emal EMPIebts
I
1--
--- ---- --- -
:1 F
--
-
..
,I,,
aheammlmal pain eMememnl dklelsmal Zlb
1ebarues
Sheewedsomiriu
_1~
lack paln
leo mettie Iljak@g *bems video
,I Pale)
There are 105 complete programs in IMR-E V1.0. Each chief complaint module allows the physician to create a paragraph customized for a given patient by using the mouse. Each program manages between 20 to 50 objects, which are displayed on 3 to 5 screens. The following is the first screen for the Abdominal Pain Chief Complaint. We can select the appropriate options by simply clicking on them, except that the number 12 must be typed or written with a pen. fIIemins 'aSi n
gattea---
nsl -'Draltio"~
a
iute1
IZ
Immimail variable
mineutes
irmit
dogs
eioi
Weeks
months
medllaleion
Leotlii
eourse decreasing
right upper quadrant left upper quadrant
recurrent
pariumbelical ar
constant
epigastrhu.m
left
783
WMATRT
IV
_UMBU&M
0195-4210/92/$5.00 © 1993 AMIA, Inc.
S
AUmOITAX L COWLAU
II MEW MOR
-
MI
aowe quadrant
left sheidder
back &
n right flank
*
Ielpigastrium right upper quadrant adrea
1A'
. |;~ I
The following is an exanple of a History Screen. By selecting the HISTORY folder we can enter all of the history information.
LnntQa.Pm. kI .P.Afl1taI 9 db. .9. .0.gy.......r. .......... Q,1 .S±^.t. 1 J n.L@fl..... OPa&1J P.PW.fi.d.-mimi X.4QD. QQ1C.1L. +..Waf4Qnttni.nz.lonLLQonAablJ.QwtprsuoAwiiL... CC I fl1 ~ ~ ~ ~ Q .Qmcm0anA ..
CC.1 eI tA.tmInj.penflgpAac L4tb.§y
eTm
Anhwtheri.zedwt ebinb..... C .1... C.HZ±+.A Q;nci.n 6L :CC. 1 .CH3±LabNmy)yJl.an chorterizcd as stabbinj CC. 1 3AS18 +±ardwi.onwsuarPsocm edrWithtevor ....... 4i nki alpan .soc.mted.'.wtt.h.s.aujet ,C.C 1.A.S 1 L9t|.a.P,.. ,MEDS *97 t.fBEN*2AI.THI!NE P..EIJqC.1LIJN G A9 7.............. ,PMHCY 38 .. Cerdio%ecuIer PulmonwyHypertension C.... l. .8...+..ap...... . .nd .u... .a. . a...t.e. . ..pw.....
i i 5
Naeymi-Aed. Frank
1i/10/5s 1111443333 Daue Trace
M.D.
urr leo t
TR
-ci
nj
....... A.... . .... ........ ... ..... .... ............ . . ..... ....... ..
k
w
jm
.....
.
...
.
.... .......... ......... ....... ... ...........
UL
The next screen is the result of clicking on the Physical Exam icon from the main menu: Reset
Physical Exam Nm
m m
i own"
MmmdNO..S No
M
M
a
Ew* E_ Em-ir
-M
Eme tSd
tS3
0
as bomd
20 O r
0o I
E's EtSti@O D
13
3
r)3oo Q o :o
LI
There are three options for each selection: Normal, Normal Except, and Not Examined. Not Examined will print "not examined" on the report. The Normal option will automatically print the user's custom designed normal exam on the report. The next screen demonstrates an example of the Palpation/Percussion screen. leset
I I
patient-specific termns
oal
a_ ReAound toodemuess Rigidity Iguarding$ Liuer paipable Spleen paipable Rbdominal mast paipablo
The patient Is a 41 gear aId married whiie male with __81NKK19 who presents Luith complaints of abdominal pain. The onset o1 the abdominal pain has been suddNs and has been occurring for 12 hours. The pattern of the abdominal pain has been persistent. It's course has been Increasing. The abdominal poln is loeated In the right lower quadrant with radiation to the left flank end left lower quadrant. 11 is aggravated bg coughing, standing end walking while relief is obtained bg nothing. Th& abdominal pain Is characterized as sharp and stabblnq. The
A list of
i.......
D... ....................
Clicking the text icon displays the current status of the electronic report that has been compiled in the background throughout the dhata entry process. I
an
H.ad.. CC .CI.C 1.a^ RE A..+... a.P.§qi.. . .4.. n..a. ml.A.tQ. XQA . o .t...i....... .... IJ..... ha-r. P.. .. .... 1+±L4Lr'S...
By selecting the PAST MEDICAL HISTORY Folder we get to the next screen. I
.
.
LL
OsCI esteY
.
.
HISThEY
T
t2 .4iP9fl.QM............... ................ d.Zino.h9.Mm
.c P.a^|. ttQWj
a
Dullness to percussion Tgmpanhc to percussion Shifting dullness Fluid woue Ubturatar sign Psoes
r--.
NS3I
Absent
Senenil ls |"lc
'Pt
r~ quadranti
sign
quit
is also
generated
in the
background during data entry. These terms can then be sent to expert systems for consultatiions, quality assurance systems, and literature retrieval systems. IMR-E currently generates 165,000 tenns.
We present a user-friendly, comprehensive, computerbased patient record (CPR) that can handshake with medical expert systems. Pilot studies with IMR-E have generated substantial enthusiasm. We plan to connect IMR-E to existing drug interaction progruams and billing programs in an effort to establish the initial components of a physician's clinical workstation.
784
