One of the important units in the he alth information system is the electronic medical record. Almost every medical institution faces this document, doctors, nurses and extras use it in their activities. In accordance with GOST, an electronic medical history refers to the type of medical documentation on which the quality of care depends.
Why do we need electronic documentation in hospitals
The predominant part of information systems in the he althcare sector involves the desire for complete automation of accounting functions (accounting for services and consumables), and the creation of a high-quality electronic medical record and the examination of the quality of care for patients are actually secondary issues. It is not surprising that such informatization complicates the work of medical staff and causes difficulties in implementation.
Keeping an electronic medical record with proper implementation is mucheasier than the usual medical records on paper in the understanding of most Russian doctors. This form of documentation has a number of advantages:
- deprives doctors of the need to do routine "paper" work;
- minimizes the likelihood of medical errors;
- helps improve the quality of care through a wide range of expertise and analytics;
- increases the level of patient confidence in the medical facility.
The doctor always has the opportunity to print the results of the study, examination, get acquainted with the recommendations of other specialists, their medicinal prescriptions. The patient also has the right to receive an extract and any necessary information in his hands. To do this, he needs to contact the registry of the medical institution. In addition, it is possible to extract the necessary information for accounting from the electronic medical record (GOST R 52636-2006), while it is important that there are no inconsistencies and inconsistencies in the reporting documentation. For example, when the service is paid for and mentioned in the accounting department, but nothing about it is indicated in the patient's medical record.
He alth information standards in Russia and abroad
Problems in the field of informatization of medicine are discussed regularly in our country. Being supporters of the introduction of electronic systems, many experts consider international and European standards as exemplary. Electronic medical history systems are based on the experience and practice of foreign doctors. At the same time, it is difficult to name a country in which the issues of transition frompaper records to electronic could be considered completely resolved.
The main reason for the imperfection of informatization in different countries of the world is the variety of standards and information systems that constantly compete with each other at the development level, as well as the failures of significant and very promising European projects. That is why it would be wrong to classify Russia as an outsider in this area. Informatization institutions of advanced countries are still in the starting position, including the United States: here, the relevant projects for automating the execution and maintenance of medical documents are approximately at the same level as our domestic ones.
The implementation of such programs largely depends on the national characteristics of the he althcare system, so it is far from always adopting the experience of other powers is an appropriate and useful solution.
What is "BARS"?
An electronic medical record does not exist on its own. You can create such a document within the framework of a special information system. One of these is the BARS Group. This is a universal tool for automating the work of medical institutions, regardless of the profile and specialization, the number of branches, medical centers, etc.
This information product involves the creation of functionality for automatically accounting for all stages of the diagnostic and treatment process, from making an appointment with a doctor and issuing an electronic medical record, andending with document management, financial reporting. The information systems of BARS Group are also intended for the formation of individual projects, taking into account the needs of a particular institution.
The core of the patient's electronic medical record created within this system is a simple computer program that allows you to efficiently and effectively organize the work of the clinic by automating all cycles of services and business processes.
The advantages of the BARS medical information system include:
- guarantee of productive work of medical staff;
- increasing visitor loy alty;
- serving existing customers and the possibility of attracting new ones;
- quality management of resources and control over the patient flow in order to analyze competitiveness;
- the ability to objectively assess the quality of services provided and work to improve it.
The system has a simple and uncomplicated interface, which is very convenient for users who have only basic computer skills. Users can access electronic medical records not only in the hospital, but also anywhere in the world via the Internet.
The system has a centralized database with secure remote access for users. For doctors, nursing staff and patients, there is a client mode through a Web browser that operates in any operating environment (Microsoft Windows, Mac OS, Linux, etc.). The information system itself is built on what IT professionals call the basic principle of the three-tier architecture. It includes an Oracle database server and a Web server, as well as a Web browser. This complex provides high reliability of stored data and provides great opportunities for information integration.
Users of electronic he alth records
Speaking of electronic patient records, one should understand a set of software and hardware methods and tools that allow you to completely avoid the use of paper information carriers in the process of their diagnosis and treatment. Moreover, the use of this term does not necessitate the actual abandonment of paper documentation and x-rays, which, due to various circumstances, will be used simultaneously with the electronic medical record for a long time.
The conditions for using information systems do not contradict paper workflow, therefore there are no barriers to their parallel existence. In this context, the question arises as to whether developers should lead the process of implementing information systems in such a way as to achieve a complete transition to paperless technologies. In the near future, it is planned to complete the implementation of the project, which would allow most departments of the medical institution to solve many problems. The electronic medical record is intended for several user groups with different goals.
So, for example, for the administration of an institution, electronic medical records serve as a tool for operationalcontrol over the treatment process. Thanks to the introduction of the information base, the head physician, heads of departments, employees of the department of medical statistics and the registry have the opportunity to receive reliable generalized information at any time.
Electronic medical history provides constant access for ordinary medical staff to detailed information about patients, their medical history, previous appeals. For scientists, medical records are objects of regular data collection and analysis used in development and research. The electronic medical history also plays a role for employees of the planning and economic structures of the institution. The medical card helps to track financial transactions during the medical and diagnostic process.
All of the above user groups have their own vision of the role of the electronic medical history, and therefore the system implementation process has its own requirements, which often turn out to be contradictory. In this sense, the task of the project managers for the introduction of electronic medical records is to find a reasonable compromise between users at all stages of development and modernization of the system.
Internal content
What document regulates the structure of the electronic medical record? The goals and principles of standardization in the Russian Federation are clearly defined by the Federal Law of December 27, 2002 “On Technical Regulation”, and the rules for the practical use of national standards of the Russian Federation are GOST R 1.0-2004 “Standardization in the Russian Federation. Basic Provisions". Basicthe legal act that regulates this area of he althcare informatization is the national standard of the Russian Federation "GOST R 52636-2006 Electronic medical record".
Automated medical records can be classified according to the type of information they contain. All information in the electronic patient record consists of several parts:
- formal part, including passport data, nosological form, general description of manipulations, conclusions of consultants, diagnosticians, etc.;
- partially formalized information (description of complaints and symptoms, assessment of the general condition of the patient upon admission to a medical facility, laboratory test results);
- information that cannot be formalized.
The last category includes the anamnesis itself, comments by the attending physician or other highly specialized specialists about the diagnosis, patient observation diaries and other sections that require a detailed, but not always corresponding to any standards, description. Moreover, the division into several groups is caused not so much by the amount of information, since this factor is not of fundamental importance for automated processes, but by the possibility of their consolidation. The electronic medical record template contains the following data:
- admission information (date and time, initial diagnosis, condition at the time of arrival);
- codes of departments during hospitalization (if the patient uses paid services);
- clinical diagnosis based on examination;
- discharge date;
- statistical information;
- data on visits and services provided;
- documentation of primary and follow-up inspections;
- diagnostic results;
- forms of sheets of temporary disability;
- protocols of surgical interventions, anesthesia care;
- card of stay in the intensive care unit.
What are the requirements for an electronic medical record
In accordance with GOST 52636-2006, an electronic medical record is not prohibited from being used as a primary medical document. Such a medical card contains records of regular observations of the patient, prescribed diets, prescription sheets, laboratory tests with results, notes on manipulations, physiotherapy, massage sessions, exercise therapy, etc. Discharge reports in most modern clinics are also compiled electronically. You can get an extract or a certificate from a medical card much faster.
The medical record in electronic form goes through the mandatory stage of coding - this is an automatic update operation in the system of information regarding medical prescriptions and the patient's diagnosis. In addition, in a similar mode, the statistical coupon is automatically filled. The use of an electronic medical record and related programs, additional subsystems contributes to the final transition to electronic document management within a polyclinic, inpatient or other departments of a medical institution.
In accordance with GOST,An electronic medical record must meet a number of requirements. Of particular importance is:
- availability of all information related to the description of the patient's state of he alth, previous examinations or treatment;
- guaranteeing the use of the system by patients and medical staff of a medical institution on an equal footing;
- impossibility to change already made entries in order to protect information from falsification;
- remote access;
- receiving data for generating accounting reports;
- availability of information that may be required for specialized examination.
The main problem limiting the maintenance of an electronic medical record is the lack of a clearly developed mechanism for restricting access and prohibiting retroactive changes to records, as well as the lack of detailed information about each record (who created it and when), weak protection against leaks.
Electronic patient records in polyclinics
Today, we know about several models of electronic medical records and a number of programs that are used in medical institutions, including public hospitals. The polyclinic is the main place where patient records are generated. In some institutions, an electronic document management model is used using personal electronic digital signatures of patients, usually hardwired in a medium (USB key, social card, etc.). It can also store he alth insurance data.
The second copy of the electronic signature is stored electronically. The keys are sent to the institution's encrypted vault. All specialists and nursing staff have their own personal key on a tangible medium, which provides them with access to an electronic filing cabinet. Each entry into the database is recorded, and a record of all access episodes is automatically generated. After each patient visit, a new XML file is created, which is signed with the doctor's key and encrypted with the patient's digital signature. These actions confirm the identity of the specialist and the patient, at the end the recording date is indicated.
To get remote access or create a backup copy of the electronic medical record, you need to synchronize the database of the medical institution with the federal server, which also provides protection against falsification and forgery of information backdated. At the same time, it is impossible to read the records on the federal server itself, since this requires the personal keys of doctors and patients.
If the patient wants to go to another medical facility or requires hospitalization, he needs to take his key and give it to the temporary storage of the staff of this hospital. This will allow remote access to the main map and new entries. To do this, you must first request information from the local server. If it is not available, then a request is sent to the federal databases. If a patient does not have a valid key during hospitalization, a temporary key is generated for him, which will be used to maintain a medical record. At the same time, dailyto synchronize data with the federal information base.
Risk of information leakage
In any example of an electronic medical record, information for reports is contained not only in the medical record itself, but also in a separate database of a medical institution. Part of the data on the patient's visit and appointments is automatically transferred in the form of depersonalized information, which can be used to easily determine the number of occupied and free beds, and calculate the percentage of morbidity cases. The installed triggers provide automatic filling of the diagnosis fields and the issuance of an extract.
Knowing only about the general provisions of the electronic medical record, it is easy to conclude how convenient it is to use. The attending physician and any narrow-profile specialist to whom the patient turns about his illness will have access to the entire medical history, and not its individual fragments, extracts. At any time, the patient has the right to demand the provision of this or that information on paper. Moreover, the security of the system is ensured even if some kind of failure occurs in the program: in this case, backup copies of the material are automatically created. It also provides protection against illegal modification of records and information leakage.
At the same time, there are weaknesses in the electronic medical record. In the Order of Rostekhregulirovanie dated December 27, 2006 N 407-st., Ed. dated 2009-01-06), which approved GOST R 52636-2006, there is no clear limit on the number of possibleexamination before a court decision. Today, under standard conditions, several examinations can be carried out on the basis of an electronic medical record, and if access is granted to everyone who requests it before a court decision, the risk of confidential information leakage will increase.
Key benefits of electronic medical records
Entering information related to the examination and test results, other medical information is carried out directly when creating records by doctors of various speci alties (therapists, surgeons, otolaryngologists, ophthalmologists, cardiologists, pulmonologists, infectious disease specialists, etc.). The electronic he alth record modules come with completed data entry forms. They are developed with the participation of doctors using systems that have been debugged over the years and are used in medical institutions in the public and commercial sectors.
The information system assumes the use of tools designed for faster text entry. Contextual directories are assigned to input fields and give out phrases and terminology that are most common. Thanks to the hierarchical structure of reference books, it is possible to construct long phrases. Installing a standard module of the electronic medical record provides for the inclusion of many directories at once, available for self-addition, and the current search mode allows you to quickly find the necessary terms in the directory. So, for example, thanks to pharmaceutical reference books, a doctor can prescribe a medicine according to a ready-made template, indicating only individualparameters (dosage, duration of treatment, etc.).
Based on the general provisions, the electronic medical record is a convenient systematized tool that allows any user to quickly enter information about the patient. The information system ensures maximum security of access to a medical record in the presence of access rights and keys in the format of an electronic digital signature. The most popular MIS "BARS Group" allows you to view patient records and quickly find the necessary data in any volume. When using the macro substitution function, it is possible to copy information from previous records of the medical record and facilitate the entry of the same type of formal information (operation protocols, observation diaries, preventive medical examinations, etc.).
On the basis of an electronic medical record, the user can generate statements, certificates, print them or store copies of these documents, as well as visually view information about the patient, previous episodes of his illness, get acquainted with the expert opinions on the diagnosis, prescription lists.
In the electronic form of the medical history, it is convenient to create protocols for specialists of any profile. Doctors have the ability to attach documents and even voice messages to the card. The format of the electronic medical record allows you to transfer it on any media that can be connected to a computer or other devices for viewing or making changes. In the BARS medical information system, the patient's electronic medical record module is closely integrated with such system modules as financialaccounting institution, bed fund, pharmacy, etc.
Finishing
The electronic medical record has long ceased to be considered something strange and outlandish. Today, this information tool is used by most medical institutions, many medical institutions are showing interest in it and are already preparing to implement this system. In order for the electronic medical record to become an indispensable element of the hospital document flow, the administration of the institution must set step-by-step goals and consistently resolve issues related to the use of an automatic information block.
The regulatory legal act that establishes the rules for maintaining an electronic medical record is the order of Rostekhregulirovanie. Its publication made it possible to significantly facilitate the work of the staff and automate the process, partially eliminating the need for endless paperwork. The program helps doctors create records, analyze medical history, treatment terms and take into account other information contained in previous records about diagnoses, prescribed therapy, complaints, procedures.
