Multimedia clinical records: results of a pilot project at the Radiation Therapy Department of Florence

Abstract

A system based on Macintosh, Hypercard and a local network was developed at the University and Hospital Department of Radiation Therapy, Florence, Italy, to manage the clinical records as a complex data structure (data, texts, drawings and image storage and retrieval). After 4 years, the system produces over 2000 new charts a year and manages more than 15,000 clinical records. Electronic records are produced, printed and updated in their traditional form to be put on file in our archive. On-line consultation of the clinical records is possible from every workstation of the structure even as it is producing, updating, or printing a chart. Physicians and clinical clerks, with different access privileges, currently use the system for all these purposes. The clinical records are typed by secretaries who receive dictation on microcassettes. No extra staff were necessary to set up and manage the system and training was simple. The new system changed neither the organization and structure of the traditional records, nor the flux of information; new tools (computers, printers and a network) were introduced to manage the information and the charts. The author describes the aims of the original project and the results.