A Computerized Patient Information System in a Psychiatric Hospital

The advantages of electronic patient records have been discussed extensively (1,2,3), and there is an abundance of literature on how to implement these information systems (4,5,6). Nevertheless, the efficient implementation of electronic patient record systems is yet to be achieved at many institutions. Most systems are dedicated to specific medical fields or tasks and must be integrated into a hospitalwide information system (5).

The Mayo Clinic has reported on its success in converting laboratory data into information that can be used to improve patient care (4). Prescription management systems have been designed to facilitate accurate prescriptions, which has reduced pharmacy costs (2). Greemes and associates (4) and Modai and colleagues (7,8) have noted the importance of alert systems in clinical practice. Knaup and associates (5) have described heterogeneous hospital information systems aimed at supporting physicians in their daily clinical work. Cost-effectiveness and quality of care are also major considerations (9).

Here we describe a computerized patient information system being used at Sha'ar Menashe Mental Health Center in Israel. The system is a fully implemented work instrument that promotes clinical safety and cost containment.

Structure and functions

The computerized patient information system, which was implemented in our hospital in 1997, runs on a Novell local area network (LAN) that includes 150 workstations and is installed in 17 units. The system provides for all practical patient-related needs: medical files, correspondence, dictionaries, hospitalization summaries and reports, laboratory test results, prescriptions, assessment scales, and patient labels (10). The database—called CLICKS, for clinical records—is a commercial product of Rosh-Tov Limited, Beer-Sheba, Israel.

The first author began using CLICKS in the hospital's psychiatric department. Patient records maintained by the department include demographic information; personal and medical histories; records of the initial patient interview, daily functions, and follow-up information from nursing staff; assessment scales; vital signs; current psychiatric status and diagnosis; follow-up information on medication and information from psychiatrists, psychologists, social workers, criminal justice personnel, and occupational therapists; expert consultations; and results of imaging tests, physical examinations, and laboratory tests. Previously entered information automatically appears in the appropriate fields on the screen. All frequently used expressions, jargon, and codes are retrievable online. Individualized internal and external correspondence can be produced automatically, as can medical and statistical queries. Laboratory results are automatically entered into the patient's record. Cross-check reports alert the attending staff to pathological or missing laboratory results (7,8).

The patient information system is exceptionally user-friendly and thus was readily accepted by the medical staff at the hospital. In addition, the hospital director was personally involved in training all staff members, one department at a time.

Changes in clinical practice

Therapists working at individual workstations enter data directly into patients' files. The therapist generates medical instructions, prescriptions, correspondence, holiday passes, hospitalization summaries, and assessment scales as well as nursing, scheduling, and cross-check reports. Printouts are signed as required by law. Staff meetings take place in front of computer screens rather than over handwritten files. The use of pencils is minimal, and secretaries rarely type letters from scratch. Each department head reviews all follow-up visits and appointment schedules.

The attending psychiatrist enters queries into the patient's record, and the nonpsychiatric consultants—for example, neurologists and internists—review these queries daily in their offices, entering the required information directly into the patient's file in the case of recurrent problems or responding to the query by telephone or by visiting the patient. Data can be entered either from the psychiatric department or from the consultant's office.

The pharmacist can produce medication reports for all patients in the department and for individual patients and supplies medications on the basis of dosage information in the system. The hospital director can reply promptly to internal and external questions or requests by retrieving information in the system. General statistical queries are easily processed. Cross-check reports produced daily in the general director's office enable the director to supervise clinical work in the various units from his workstation.

Quality of care

Automated entry of laboratory results and the ability to cross-check reports means that human error is reduced and that clinical problems can be identified more quickly. Automated medication reports and prescriptions improve the safety of drug administration. Multiparty expert consultations can be conducted online, and all the pertinent data are readily accessible by all parties.

In the past year, cross-checking from the hospital director's workstation generated 70 consultations, many of them related to blood lithium concentrations and agranulocytosis associated with clozapine or carbamazepine treatment. Eight patients benefited from early detection of irregularities and initiation of critical medication adjustments.

Cost containment

The initial investment in the LAN was about $400,000 for hardware, software, and optic communication lines covering the 740,000 square meters of hospital property. After the system had been in operation for one year, a saving of $127,000 was recorded, of which $87,000 was related to food expenditures and $40,000 to medication expenditures. However, a network engineer was hired for $50,000 a year, an additional $10,000 was spent for annual maintenance insurance, and an annual increment of $32,000 for equipment has been estimated. Thus net operational savings are $35,000 a year, and a return on the investment is expected within 11.4 years.

The costs of human resources were not calculated, because the hospital is a government institution that does not have the option of downsizing. It may be possible for a private institution to realize additional savings by reducing the use of secretarial services by 25 percent. Reduced human error and an increase in the number of online expert consultations are likely to result in lower litigation costs, which should hasten the return on the investment.

Discussion and conclusions

Security and confidentiality issues related to the computerized patient information system are covered by Israeli law. All computers with the system installed are located in offices that have bars on the windows and are locked when not being used. For protection against unauthorized access to confidential information, these computers do not have modems and are not linked with any external networks. User names and passwords enable graded access to confidential files by different staff members.

User-friendliness, the personal involvement of the hospital's director, and hands-on experience have been crucial to the successful implementation and acceptance of the computerized patient information system. The system can be adapted and upgraded to meet changing needs. Given the economic and patient care advantages of using a computerized patient information system, it is difficult to understand why such systems are not more common in public and private psychiatric institutions.

The authors are affiliated with the Institute of Psychiatric Studies of Sha'ar Menashe Mental Health Center, Mobile Post Hefer 38814, Israel (e-mail, [email protected]). Dr. Modai, Dr. Ritsner, and Dr. Silver are also with the Bruce Rappaport Faculty of Medicine, Technion, in Haifa, Israel.