Development and implementation of a medical record system for the Istituti Clinici di Perfezionamento public network of outpatient specialty clinics in Milano, Italy

The Istituti Clinici di Perfezionamento of Milano (ICP) Hospital, Italy took the charge of managing the network of 22 outpatient specialty clinics of Milano in 2008. Within these clinics 650.000 visits are performed yearly by 255 specialists of 26 different specialties. Until 2008 these clinics have been managed by several different Public Hospitals, there was no unique standard for paper medical records and only a minority of patients encounters were registered electronically. ICP is one Public Hospital of the Lombardia Region, which had developed a Health Information System called SISS. SISS allows all the entitled public health professionals to gain access to individual patient records which contain demographic, clinical and service utilisation data registered with SISS standards. Furthermore, standards for both paper and electronic hospital records have been clearly defined by the Regione Lombardia. In this context ICP started a program for the development and implementation of an outpatient specialty clinics medical record system that took off at the end of 2009. A project team was settled, composed of specialists\u2019 representatives, quality management and organization experts from within the ICP. In six months the group defined: \u2022 The outpatient medical records general structure and format standards \u2022 The structure and content of the medical documentation for 10 main specialties that cover more than 90% the ambulatory visits and more than 75% of the specialists \u2022 The functions needed to integrate patient clinical and administrative management \u2022 The implementation plan of the medical record system, comprehensive of the evaluation of logistic, hardware, medical education and quality control needs within each of the 22 clinics \u2022 The overall medical record system architecture in order to integrate future development with the opportunities offered by the SIS