MEDINF098
B. Cesnik et ale (Eds)
Amsterdam: lOS Press
© 1998 1M/A. All rights reserved
Model of Computerized Academic Medical Clinic
Daniel Sigulem", Silvana S.F.X. Gimenez", Alberto Cebukin", Orlando Lima Cardoso", Maria Susan
Chern", Monica Parente Ramos", Meide Silva An~a~a, RudolfWechslerb , Carlos Roberto Serachi'',
Humberto Bracco Netto", Samuel Goihman''
aHealth Informatics Center - Federal University ofSlio Paulo - SP, Brazil
bDepartment ofPediatrics - Federal University ofSiio Paulo - SP~ Brazil
clnstitutional Data Integration and Evaluation Coordination - Federal University ofSiio Paulo - SP, Brazil
Abstract
In the traditional medical graduation course, the student
receives a great amount of information while training at the
Outpatient Care; the student assumes the physician's role, col-
lecting all the information regarding the patient's clinical his-
tory and learns to get along with patients as well. During the
attendance process, several factors interfere in the academic
teaching, such as limitations of room numbers, amount of
patients, difficulties in obtaining medical records, paper illegi-
bility, among other problems.
Due to those difficulties, the Model ofComputerized Academic
Health Clinic, implies in a new learning paradigm in the medi-
cal practice, rethinking the traditional process of learning-
attendance, where the old model, in which attendance is
restricted to a place, is extended in an open atmosphere of
,shared knowledge, rich ofcomputer resources.
The pilot project was implanted in the Pediatrics General
Health Clinic of UNIFESPIEPM It allows that the fifth-year
medical students, residents, trainees and tutors use computer-
ized clinics" connected with the academic net of UNIFESP and
to the Internet.
All the computing and information resources settled at the Out-
patient Care improved the organization of its services,
increased the medical students' curiosity, improved their partic-
ipation in learning through interactive programs and clinical'
attendance.
Keywords
Medical Informatics; Medical Education, Computerized Outpa-
tient Care; Educational Paradigm changing
Introduction
The amount of information in the Health area is increasing rap-
idly, making the students access to most of this information,
particularly during graduation course, much harder.
Nowadays, the traditional teaching methods used in the main
education institutions in the Health area are based on old meth-
odologies, where few students gather around in the classrooms
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for information acquisition.
In this traditional teaching method, the main knowledge source
is the teacher's figure, that brings all the information that he or
she believes it is important, exposing the students to the theoret-
ical content in a certain period of time, pre-established by the
curriculum of the course.
Today, there is a great distance in the relationship between the
student and the teacher, where the last just concerns in transmit-
ting knowledge. This issue is one of the greatest paradigms of
the education, where it is known that the concepts, learning and
teaching, are not synonymous in the educational process.
In the medical graduation course, most of the learning process
happens at the Outpatient Care, where the student assumes the
physician's role and learns, dealing with the patients, elaborat-
ing diagnostics hypotheses, requesting lab exams and choosing
the best conduct for each clinical case.
Several factors interfere in the academic teaching, such as lack
of room numbers, huge amount of patients, difficulties in
obtaining patients' medical records, paper illegibility, among
other problems. Many efforts have already been made in
attempting to improve the students' education, particularly in
the Health area. The use of modern computer and telecommuni-
cations tools reveal as promising resources.
Believing that Medicine teaching should go by under transfor-
mations, the Health Informatics Center (CIS-EPM), presented
to the Federal University of Sao Paulo (UNIFESP), a develop-
ment proposal and implantation of a new teaching and learning
methodology, based on the use of a microcomputer net with a
number of systems available, in which the clinic management
and patient's information evaluation system is the core soft-
ware. It allows access to a lab exams database, procedures, edu-
cational programs, decision support systems, dictionaries,
electronic-mail, and to the Internet, as well.
The first section of computerized academic attendance was the
General Health Clinic of Pediatrics, that assists 7000 annual
consultations, approximately, and receives about 100 students,
45 residents and trainees a year. Using the computing and infor-
mation resources provided, the student can assist and follow the
patient in a fast, organized and effective way. As a result,
papers are left aside, the time of attendance decreases, and the
patient's clinical data are better organized.

D. Sigu/em
For several years, UNIFESP, has been developing new method-
ologies for the improvement of health teaching as well as for
research, such as the implementation of a academic network
linking together all its departments to computing and informa-
tion resources such as educational programs and to the Internet.
Objectives
1. 'create a new medical teaching paradigm,
2. develop and to settle new teaching technologies, atten-
dance and research in the medical area through the use of
computing and information resources, .
3. validate the impact ofthis new paradigm in changing the
student's behavior in learning.
Material and Methods
The General Health Clinic of Pediatrics at the Hospital Sao
Paulo of the Federal University of Sao Paulo - UNIFESP/EPM,
was selected based on the following approaches: number of
periods at the Outpatient Care foreseen in the graduation stu-
dents' schedule, number of advisers at the Outpatient Care and
appropriate physical space.
All the Outpatient Care rooms have been equipped with micro-
computers, inter-linked to the UNIFESP's academic network
and to the Internet, allowing the use of different computing and
information resources available for the fifth-year medical stu-
dents, residents, trainees, tutors and faculty.
In the installed equipments, there is a rich group in computer
resources needed for the establishment of a environment called
"Learning Environment at the Outpatient Care", composed of: a
clinical information collection and analysis program, developed
by CIS-EPM, medical softwares (decision support, pharmaco-
logical interaction and etc.), educational programs; electronic-
mail and the Internet - allowing communication, at any time,
with the teachers, located in different points of the university
campus or outside, lab exams database access, 'which contrib-
utes, in a way, to activate the results verification and the perti-
nent patient information exchange.
Twenty three professionals involved' with the tutoring were
trained, totaling 6 hours of theoretical and 12 hours of practical
classes. The aim of this training was mainly to illustrate the
tutors' doubts. Since they are responsible for the students, resi-
dents and trainees support. Periodically, complementary lec-
tures and classes, sessions to clarify doubts, support through e-
mail and monthly follow-up meetings with all the users.
Development Platform
1. Hardware
The hardware infrastructure was built and implanted for the
Outpatient Care which is composed of 8 attendance rooms, 1
management room, 1 discussion room and 1 room for clinical
cases preparing; each room contains 1 microcomputer PC inter-
linked to the Academic Network and to the Internet, multimedia
kit and 1 printer.
769
2. Software
• Clinic Manager 4.0 - management medical information
program, developed by CIS-EPM of UNIFESP;
• Decision Support System in Nutrition 2.5, Decision Sup-
port System in Renal Lithiasis (Ad-Lit v. 1.0), Evalua-
tion system of the Nutritional Status in Pediatrics 1.0 -
medical software and decision support systems devel-
oped by CIS-EPM of UNIFESP;
CD-ROM of the electronic book: Modem Therapeutic
Practice - developed by CIS-EPM of UNIFESP;
• Educational Program in Ophthalmology, Breast Feeding,
Dermatology and Cardiology educational programs in
multimedia developed by CIS-EPM ofUNIFESP;
Quick Medical Reference 3.8.1 Copyright © 1995 Uni-
versity of Pittsburgh and the Hearst Corporation - deci-
sion support system in Internal Medicine; composed by
signs symptoms and clinical findings, that help to elabo-
rate diagnoses and to improve the quality of the thera-
peutics; QMR is a registered trademark of The
University of Pittsburgh.
• MICROMEDEX Healthcare Series for Windows -
Micromedex, Inc. - drug information system;
• Mayo Clinic CD-ROM Collection Copyright © 1996-
1997 Mayo Foundation for Medical' Education and
Research. (Cardiology, Pneumology, Neurology, Pre-
ventive Medicine, General Clinic, PRiMEPractice, a
CD-ROM Quarterly for Primary Care Physicians, IVI
Publishing) - data base on several Sciences subjects;
• Novell Netware - net management programs;
• Microsoft Windows 95 Copyright © Microsoft Corpora-
tion - 32 bits operating system;
shield for Windows - anti-virus for Windows;
• Microsoft Office 97 Copyright © Microsoft - Corpora-
tion - administrative system;
• Pegasus Mail for Windows Pegasus Mail for Microsoft
Windows Copyright © 1992-97, David Harris, all rights
reserved - electronic mail application, which allows:
communication, at any time, among the students and
with their teachers, located in different points of the uni-
versity campus or outside;
• Netscape Navigator 3.0 Copyright © 1994-1996 Net-
sc~pe Communications Corporation, All rights reserved
- browser for access to electronic mail and to the World
Wide Web.
Patient Attendance
To characterized the patient's attendance as an outpatient care,
the patient is registered in the SAME (Medical Registry and
Statistical Service) of Sao Paulo Hospital.
For the patient's follow-up, the medical record has to be first
requested to the SAME, in about a week earlier, so the cases
can be previously discussed to the attendance and the clinical
staff can plan, in advance, the best treatment strategy for this
patient.
The computing and teaching integration during the attendance
770
Education

practice and the case studying, is one of the professionals' main Table I - Apprenticeship's length
objectives involved in this project, not disregarding the relation-
Staff Time (months)
ship between doctor and patient based on the attendance dig-
nity, where the patient's follow-up becomes fast, organized and Students 1
effective. Residents (Rl) 4
Residents (R2) 3
Evaluation
Trainees (TI, T2) 2
The methodological approach for conducting the evaluation is
apprenticeship, happens between 90 to 120 min., at the end,
based on the accomplishment of questionnaires, interviews and
approximately, 80 min.; the patient's follow-up occurs at the
participant's observation.
beginning of the apprenticeship between 60 to 75 min. and at
The survey of student's attitudes, values and behaviors during the end, approximately, 50 min, as shown in Table 2.
the use of computers in the patient attendance has as main pur-
pose to detect the impact of the computing and information Table 2 - Attendanceperiod at the Outpatient Care
resources, including hardware and clinical management, educa-
tional and support programs in the teaching quality and medical Staff Activity APl* AP2**
attendance. (min.) (min.)
Students Consultation 120 - 150 60 - 90
Evaluation Method Follow-up 90 - 120 40 - 50
Residents Consultation 90 - 120 80
1. Questionnaires: the questionnaires were simple, distrib-
uted in the attendance rooms or through the electronic- Trainees
mail; Follow-up 60-75 60
2. Qualitative interviews and Focus Group: these inter- *AP I: Attendance period (beginning)
views were driven individually or in group (focus **AP2: Attendance period (end).
group), to obtain useful information for the evaluation
(data analysis); Through questionnaires, interviews and participants' observa-
3. Participant's observation: the evaluator was at the place tion, we obtained the following results:
of interest, that is to say, participating effectively in the 1. at the beginning of the system implantation, the group in
events that happen, making detailed annotations of the charge of the patients' attendance demonstrated insecu-
scenery and of its participants. rity, fear and anxiety when using computers to store
patient's information instead of using paper-based medi-
Results cal records;
2. on the other hand, there were a great. expectation and
Since the beginning of the project implantation at the General curiosity for the new challenge;
Health Clinic of Pediatrics, the system was used by 94 medical
3. the consultations at the beginning of the students'
students, 30' residents (RI, R2), 14 trainees (TI, T2) and 10
apprenticeship were delayed, due to their lack of famil-
tutors. Children attendance is accomplished per day by a group
iarity dealing with computers.
of 8 students and, 8 residents/trainees. All are supervised by 2
tutors. The computing and. information resources implantation
improved the organization of the services offered by the Outpa-
Daily, among 6 patients are assisted per student and 10 patients
tient Care, increased the medical students' curiosity, improved
per resident/trainee. The students' apprenticeship lasts 1 month;
their participation in the learning process through the use of
the one of the Rl1asts 4 months, the R2, 3 months, and, TI and
interactive software and clinical attendance. It was created a
T2 lasts 2 months as shown in Table 1. All the staff is renewed
new learning environment in which the student leaves his or her
periodically and to each new group are given instructions on
passive position (as an information recipient) of the traditional
how the Outpatient Care works, software and the system, as
teaching method to a situation that he or she commands hislher
well. The current group possesses 36 stored users, among
own consultationlknowledge.
tutors, students, residents and trainees and 1557 stored patients.
Nowadays, new technological resources are being implemented
The attendance period at the Outpatient Care varies in accord-
such as the Smart Card. Also, this experience will allow the sys-
ance with the examination type and with the apprenticeship
tem introduction at others Outpatient Care.
phase; at the beginning of the apprenticeship the first consulta-
tion lasts between 120 to 150 min. At the end of the students' Discussion
apprenticeship, it lasts between 60 to 90 min; the patient's fol- With the support ofthe computing and information resources an
low-up at the beginning of the apprenticeship occurs between enormous qualitative and quantitative jump in the education is
90 to 120 min and at the end, between 40 to 50 min. For the res- being possible" because the students can have online access to
idents/trainees, the first consultation, at the beginning of the

D. Sigulem
organized information of their patients, to database of the whole
world about a variety of subjects in Health Sciences, educa-
tional support through the use of local educational software and
of distance education. They attend computer electronic classes,
they participate in simulations of their daily practice situations
and they have a larger contact with the University teachers
through the Internet.
Aiming to supply this need, the University is investing in the
Computer Sciences area, allowing the students, as soon as they
enter in the computerized outpatient care, have already acquired
previous knowledge in the specified area.
The physician-patient relationship is gradually being restruc-
tured since the use of the computers and softwares becomes
more common. The evident results and the information regard-
ing the patients are acquired in a fast, clear way and without
generating doubts.
The people involved feel confortable to express their own opin-
ions and thoughts, doubts, what results in improving the project
through new trainings, new hardware and software configura-
tions, motivating the use of computing resources in the medical
attendance practice and in searching information.
Using the Clinic Manager system, a medical care profile can be
traced, so as to detect the main diagnoses, and to eliminate
problems regarding drugs interaction.
The implantation of the patient information management data-
base system provided: . (editors).IMIA, 1992.
improved administrative tasks turning them efficient,
agile and organized;
changed the students', tutors', residents' and trainees'
focus of attention. Allowed them to study the patients'
cases and clinical follow-up
gathered reliability and integrity to the patient data;
propitiated medical statistical analyses, one of the pre-
ponderant factors to plan the attendance profile;
built a database to store cryptographic patients' informa-
tion (anamnesis, physical exam, requested lab, diagnoses
771
and therapeutics) collected during the course of multiple
visit clinics;
recovered the clinical records in a fast way by the ade-
quate structuring of the data files in which events are
addressed to the patients. .
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