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Press Clipping from June 1995
Microsoft Magazine

Rx for a Medical Records Database

A custom database solution built on Microsoft Access helps the Special Needs Clinic focus on patients -- not paperwork

The Special Needs Clinic at Columbia-Presbyterian Medical Center in New York City provides psychotherapy and other mental health services to children an families affected by HIV and AIDS. "Our paperwork requirements are onerous," says Jennifer Havens, M.D., medical director of the clinic, which serves mostly low income families whose lives are often complicated by substance abuse and neglect. "It tends to take a backseat because when someone is in a clinical crisis, you priority is not on getting the paperwork done" The clinic needed a system that would allow it to reduce the repetition of many of its tasks, complete forms and reports more quickly, and access and use meaningful data in the quest for much-needed funding, and valuable planning information

Matthew Cavalletto and Halle Winkler -- who, in their day jobs at Evolution Online Systems, develop Internet sites and provide consulting -- recently donated their spare time over a two-month period to develop a custom medial records database built on the Microsoft Access database management system.

"The clinic was using a simple flat-file database to handle a few of the forms they used on a regular basis," says Cavalletto. "People liked it and kept coming back saying, 'Can you make this form talk to this form?' In a flat-file system, many different and complex data structures with a lot of relationships between them will bog down the system. Maintaining it becomes a big overhead issue. Clearly, this was a job for a relational database."

The developers opted for Microsoft Access, in part because of the easy graphical development environment. And, because the clinicians are very busy and many are self-described technophobes, says Winkler, "the system had to be easy to use. It had to replicate what people were accustomed to doing by hand."

Four simple steps to a solution
Getting started. Working closely with the clinic staff, the developers began by assessing how all the information is used and then prioritizing the data so it could be recategorized into tables -- containers of information that form the basis of a relational database. THen, they created a table for each category of data, encompassing everything from a patient's name and address to HIV status to the type of service provided, such as psychotherapy or psychopharmacrology.

Step 2. The second step was to identify how all of the data in these tables relates. "Most tables don't mean anything by themselves," Winkler points out. "The Service Category table, for example, has just and ID number and a field containing a service description, such as outpatient treatment. By itself, it couldn't be a form. But by relating it to other data, this information will be available and useful in a lot of different forms and reports."

The graphical relationship editor in Microsoft Access made the process of defining relationships "totally painless," according to Cavalletto. "Say we want to create a form that includes the patient's name and address, medical status, and clinician name and title. To link this data to the data in other tables, we can just drag and drop between the fields in the database. We don't have to write any code to express the links we're creating."

Step 3. Next, the developers built queries, which serve as filters for data stored in the tables. Queries allow the user to retrieve from the database specific information that is needed for a form or report, or that can be exported to another program. For example, the clinic is required to keep on file a hard copy of a report documenting each encounter between a clinician and a patient. A query can pull the precise information needed for this report from a variety of tables, such as patient's name, duration of encounter, and contact type, such as a counseling session or psychopharmacological treatment.

Step 4. Finally, the developers created computer-based forms, which Winkler describes as "the interface -- the place where the data is going to be used." Using the form designer in Microsoft Access, she and Cavalletto set up the fields and commands that make up the forms. Wherever possible, they used pop-up menus so that the clinician can chose from a fixed list rather than type repetitive information, such as clinician name or service description, each time. An intelligent approach to form creation has helped the clinic improve efficiency and accuracy. For example, when a clinician creates a new encounter form, Microsoft Access automatically identifies the encounter based on the patient name and date, such as Doe, John: 22-Mar-95. This way, all encounter reports are identified by the same convention, making them easier to track and find in files.

Customized reports -- which are useful in education and fund-raising, and in several cases, required by law -- also are important to the clinic. "Reports are easy to built because a lot of the process is automated," says Cavalletto. "You can go to the report screen, click New, and use a wizard to make a report for a particular query. It walks you through the steps and you get a nice little report."

Faster access to data brings immediate and long-term benefits
Though it has been in use only since March, the easy-to-use database has helped the clinic focus attention where it belongs: on providing care. Says Clinic Social Worker Sheila Ryan, "These children deserve the very best. We would rather be helping them resolve their problems than writing out the same treatment plans over and over." According to Dr. Jennifer Havens, "Day-to-day tasks are made easier with this program. Repetitive fields automatically pop up in menus, so there's less data that has to be entered. Plus, all the records are in one spot, so a clinician doesn't have to go through 700 pieces of paper to get the information needed."

Dr. Havens points out that the database brings long-term advantages to the clinic as well. With Microsoft Access, data can be directly exported for analysis in other programs. The clinic uses Microsoft Excel and a high-end statistical package. "With the new system, I can export data directly into Microsoft Excel instead of having to input it manually," says Havens. "We can access valuable data that helps us in terms of program development and education."

"If I have good data, I can show people what the service needs are."

The Special Needs Clinic is located in upper Manhattan's Washington Heights neighborhood. Crowded and understaffed, the clinic is understandably chaotic, given the pace and caseload of the staff, who see as many as 300 patients -- mostly children -- in a month.

Founded in 1991 by Dr. Jennifer Havens and psychologist Claude Ann Mellins, the clinic helps children and families cope with the emotional and mental health problems that accompany HIV and substance abuse. In less than four years, the program has grown from employing to two clinicians to a full-time staff of nine, including psychologists, social workers, research assistants, and outreach workers.

Largely dependendent on external funding, the clinic has to regularly prove its need for resources, such as more staff members. "That's why this database has been a godsend to us," says Dr. Havens. "For people to understand what kind of resources we need, they have to understand the nature of the problems our patients face. HIV is not the only problem these families have; it's not just a matter of providing bereavement counselling. These kids also face poverty and parental neglect. A significant number have learning problems or hyperactivity disorders. Many of their parents have abused drugs. You can't take care of these problems with one psychologist or one social worker. If I have good data, I can show the people what we see in a clinical stetting, what the service needs are, and what we have to do to handle this population -- and people respond much better to numbers."

The Special Needs Clinic is one of 11 U.S. sites funded by the Substance Abuse and Mental Health Services Administration's HIV/AIDS Mental Health Services demonstration program. For more information about the Special Needs Clinic, or to find out how you can help, contact Dr. Jennifer Havens at jhavens@interport.net or (212) 305-3093.

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