Information in practice The anatomy of a clinical information system

Medicine is critically dependent on accurate comprehensive data for good clinical management, audit, teaching, research, administration, financial control, general management, and statutory and legal needs. Computer technology offers solutions to the huge accumulations of clinical data in specialty and hospital medicine, yet it has not been fully exploited. The UK Audit Commission, US Institute of Medicine, and government initiatives have stressed the importance of clinical information systems centred on the individual patient. Most hospital computer systems are essentially for administration, and there have been relatively few successful clinical systems, with nephrology and intensive care medicine having progressed furthest. We describe a successful clinical system in nephrology based on an underlying flexible “generic” software package that can work in any specialty. The system is explained by reference to a general model of patient care.