Duke University Medical Center's department of psychiatry has developed an electronic medical record called Clinical Management Research Information System, or CRIS. The system has been deployed to more than 300 users, including physicians, psychologists, social workers, substance abuse counselors, and support staff. CRIS is used throughout the psychiatry department by outpatient, inpatient, child psychiatry, and substance abuse services staff as well as by the emergency department. CRIS contains information on approximately 17,000 individual patients representing 100,000 clinical encounters.
Clinicians and staff can use CRIS during all aspects of care, for both inpatients and outpatients, although some individuals use more functions than others. Clinicians are required to use CRIS to record, at a minimum, diagnosis, medications, side effects, CPT codes, allergies, and a Clinical Global Impression (CGI) score at each patient's visit. We estimate that about 95 percent of visits are captured, and considerably more information is recorded for most.
Our success in achieving widespread use of CRIS has required full support from all levels of the department. Inducing clinicians to use the system required a combination of carrot and stick. For example, adding a function for use in the emergency department that automatically completes 18 pages of paperwork was essential for the rapid acceptance of CRIS. Also, making payment of a clinician's salary contingent on the clinician's entering patient encounter information facilitated acceptance.
CRIS is a homegrown system, which has allowed us to tailor it to the needs of users and to deploy it in stages. Although this approach has made it more difficult to produce an elegant and integrated software package, we believe that it has been of great assistance in creating a system that is appealing to our clinicians. The system took approximately 20,000 hours to create. We estimate that the resulting increase in collection of accounts payable has paid for the cost of its development.
Currently, CRIS is primarily a "passive" electronic medical record, in that clinicians must take the initiative in recording and retrieving information and in gaining access to rating instruments and published studies. As we continue to develop the system, we intend to add more "active" elements, which prompt clinicians—and patients—to provide additional information and suggestions based on treatment guidelines and research.
Because of limited resources, beta testing has been done in real time by Duke staff. New versions, upgrades, and bug fixes are distributed electronically. CRIS is a three-tiered information system built for large enterprises. The front end is written in Borland's Delphi 7.0, and the middle tier is being rewritten with use of Boldsoft's object-mapping tool Bold 4.0. The back end of the application currently uses MS-SQL 7.0; however, it was written to be independent of any enterprise database.
CRIS has two linked components: a clinical record and an administrative manager. The electronic record contains all the information found in a typical medical record, such as diagnosis, medications, and results of a mental status examination, along with a treatment planner and a collection of clinical rating scales. The administrative manager streamlines treatment authorization from insurance carriers and provides aggregate reports on clinical performance for quality improvement and for regulatory requirements such as those of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
The heart of the clinical component is the individual patient record, which is divided into psychiatric diagnosis, medical diagnosis, habits, psychiatric history, social history, stressors, mental status examination, Mini-Mental State Examination, medication, family psychiatric history, review of systems, physical examination, phone notes, and a prescription writer and side effects tracker. The clinical record is protected by electronic signature.
A treatment planner is integrated with the clinical component. It follows a biopsychosocial approach and is accessible by social work, nursing, substance abuse, case management, psychiatry, and psychology staff. The planner tracks long-term and short-term goals as well as interventions and reminds clinicians and staff to complete unfinished tasks.
The clinical component also contains a library of established psychiatric scales, both clinician-rated scales, such as the Hamilton Depression Scale, the CGI, the Mini-Mental State Examination, and self-rated scales, such as the Carroll Depression Scale, the SF-36, and the Patient Satisfaction Scale. Child-specific scales are included. Clinicians can use the scales in several formats. If they administer a scale, they enter the results directly into the record. For the self-rated scales, patients complete paper forms that are then optically scanned or enter their answers through a secure Internet site. The clinician chooses the scales to administer and can view the results in tabular or graphic format.
CRIS automatically produces discharge summaries for inpatients. It includes a substance abuse module based on criteria of the American Society of Addiction Medicine. Another module guides the clinician in establishing a differential diagnosis based on a patient's symptoms and leads an interview based on MAPSO—mood, anxiety, psychosis, substance, and other-organic—criteria. MAPSO is being taught to both psychiatry and primary care residents at Duke.
The administrative manager streamlines the processing of insurance certification for treatment and also manages patient billing. It monitors insurance authorizations and completes related paperwork. The system also automatically generates bills suitable for paper or electronic submission.
All data collected by clinicians, including number and type of visits, DSM and CPT codes, pharmacy records, and results of rating scales, are accessible, and administrators and researchers can extract data by using queries that have already been developed or that they create themselves. Potential uses for these data include research, quality improvement, and fulfillment of requirements such as those of JCAHO. We export data into Microsoft Excel or Access for analysis.
Although electronic medical records have some security advantages over paper records, such as being password protected, they also have specific vulnerabilities. Currently the application meets all of the appropriate legal requirements, including those of the Health Insurance Portability and Accountability Act (HIPAA), to ensure confidentiality, including audit trails, role-based access, and so forth. However, preserving confidentiality of medical records is an ongoing and complex topic, because hackers will inevitably grow more sophisticated and the consequences of compromised psychiatric records are great.
We intend to continue to extend CRIS by adding to its functions in a stepwise fashion, according to the needs of its users. It is easy, for example, to add a rating scale or to increase the capacity to produce needed reports. Primarily such refinements require customization of the software to make it useful to clinicians in a variety of settings.
Adding more active elements will be much more difficult, both because users may resent intrusions and because understanding what is needed will require complex analyses of patient records. However, we believe that our current approach of ensuring that the system is clinically practical and accepted by its users before more complex functions are added is essential.
The vision for CRIS is to create a national repository of data on psychiatric clinical care. To that end, we intend to encourage the use of CRIS at medical centers across the country. The data repository will be a shared resource available free of charge to all participating institutions for research use. The repository will be stripped of any patient-identifying information. The University of Texas at Galveston and the Medical College of Virginia University are now using CRIS.
It remains to be seen whether customizing the software to meet the needs of clinicians can be maintained as it is disseminated to other institutions. Others may need to make their own customizations. Perhaps in the future some version of "open source" software, which places the code in the public domain and which permits all improvements to be shared, may prove most practical. However, we believe that our effort is promising in finally capturing a significant portion of psychiatric care, and we hope that CRIS will be a springboard to improved research and clinical care.
The development of CRIS was funded by Duke University. CRIS is jointly owned by Duke University Medical Center and the authors.
Dr. Gersing is a clinical associate in the department of psychiatry at Duke University Medical Center and director of the department's information services Dr. Krishnan is chairman of the department. Send correspondence to Dr. Gersing at Duke University Medical Center, Box 3018, Durham, North Carolina 27719 (e-mail, firstname.lastname@example.org). Joshua Freedman, M.D., is the editor of this column.