Preparing dermatological discharge reports within an electronic clinical information systems. A pilot investigation regarding medical and economical aspects

: The insertion of all patient details in one clinical information system (CIS) provides an enormous potential to rationalize and accelerate the administrative procedures in primary patient care. A successful data management system has to record not only the entire spectrum of the patient's medical data, but also the patient's personal data like name, address, date of birth, as well as names and addresses of other involved physicians. In addition, all aspects of the database gathered from varying sources must be compatible. The program has to be user-friendly enough that many different workers with varying backgrounds can effectively employ it. We investigated the effective saving of time in preparing a patient's discharge report based on conventional dictation using the clinical information system (Soarian) compared to a conventional, isolated word-processing program (Word). Existing potentials and limitations concerning the use of the CIS are presented. The objective analysis of measured processing times demonstrated a reduction for the typist, but no benefit for the physician dictating the discharge report. In the subjective perception of all users, the processing time appeared to have increased due to awkward editing and navigation functions. Improvements are required to increase the acceptance of the program by the users.