A computer-based system for patient care and research management in reproductive endocrinology

We describe a medical information system tailored to the operational needs of the Gynecologic and Infertility Clinic at The Johns Hopkins Hospital. It is used for patient registration and scheduling, medical and surgical record keeping, and research investigation. Data entered include a complete medical history, diagnoses, procedures performed and their outcomes, surgical pathologic study, follow-up notes, phone consultations, and laboratory findings. Data are coded individually and can be retrieved and presented in a standard or user-specific report format. The Reproductive Endocrinology Medical Information System (REMIS) was implemented over 6 months from January to June 1984. To date, 8000 new patient registrations and 3600 outpatient visits have been entered. There are approximately 100 new patient entries and 240 return visit entries per month. Preliminary evaluation of the system based on the effect on quality care, use by each user group, and research applicability demonstrates that the REMIS provides clinicians with more complete, organized, and accessible patient records to serve as an effective adjunct to clinical operations.