Implementação de Prontuário Eletrônico por profissionais médicos e enfermeiros da Atenção Primária à Saúde / Implementation of Electronic Medical Records by physicians and nurses in Primary Health Care

Objetivo: Avaliar a implementação o Prontuário Eletrônico do Cidadão da estratégia e-SUS na Atenção Primária a Saúde pelos médicos e enfermeiros de duas macrorregiões de saúde de Minas Gerais. Métodos: Estudo de método misto explanatório sequencial quanti-qualitativo. A coleta de dados ocorreu por meio de um formulário online. Foi construída uma matriz de análise e julgamento para avaliar e ponderar as questões avaliativas no instrumento de coleta. Resultados: De maneira geral, o grau de implementação de cada uma das funcionalidades (assistenciais e gerenciais) foi classificado como não adequado, mas há diferença quando se compara as profissões. Os dados mostram que a medicina quando comparada com a enfermagem tem a utilização do prontuário com escore menor, indicando que médicos informaram usar menos o prontuário eletrônico do que os enfermeiros. Conclusões: Apesar dos grandes esforços governamentais para expandir a implantação do prontuário eletrônico, sua implementação, de forma geral, ainda não é adequada. Dessa forma, a utilização do prontuário eletrônico como potencial qualificador de dados em saúde deve ser estimulada em direção à gestão e coordenação do cuidado(AU)

Objective: To evaluate the implementation of the Electronic Citizen's Record of the e-SUS strategy in Primary Health Care by physicians and nurses from two health macro-regions in Minas Gerais. Methods: Estudio de método mixto explicativo secuencial cuantitativo-cualitativo. Data collection took place through an online form. An analysis and judgment matrix were built to evaluate and weigh the evaluative questions in the collection instrument. Results: In general, the degree of implementation of each of the functionalities (assistance and management) was classified as not adequate, but there is a difference when comparing the professions. The data show that medicine, when compared to nursing, uses the medical record with a lower score, indicating that physicians reported using the electronic medical record less than nurses. Conclusions: Despite major government efforts to expand the implementation of electronic medical records, its implementation, in general, is still not adequate. Thus, the use of electronic medical records as a potential qualifier of health data should be encouraged towards the management and coordination of care(AU)

Objetivo: Evaluar la implementación del Registro Ciudadano Electrónico de la estrategia e-SUS en la Atención Primaria de Salud por médicos y enfermeros de dos macrorregiones de salud de Minas Gerais. Métodos: La recolección de datos se realizó a través de un formulario en línea, se construyó una matriz de análisis y juicio para evaluar y ponderar las preguntas evaluativas del instrumento de recolección. Resultados: En general, el grado de implantación de cada una de las funcionalidades (asistencia y gestión) fue catalogado como no adecuado, pero hay diferencias, al comparar las profesiones. Los datos muestran que la medicina, en comparación con la enfermería, utiliza la historia clínica con una puntuación más baja, lo que indica que los médicos utilizan menos la historia clínica electrónica que las enfermeras. Conclusiones: A pesar de los grandes esfuerzos gubernamentales por ampliar la implementación de la historia clínica electrónica, su implementación, en general aún no es adecuada. Por lo tanto, se debe fomentar el uso de la historia clínica electrónica como potencial calificador de datos de salud para la gestión y coordinación de la atención(AU)

Profile of pediatric patients with cerebral palsy at the Department of Rehabilitation Medicine, Philippine General Hospital

@#<p style="text-align: justify;"><strong>OBJECTIVES:</strong> Data is necessary for a hospital-wide cerebral palsy (CP) profile, this being the leading pediatric diagnosis at the PGH Rehabilitation Medicine Out Patient clinic. This study aims to identify clinical features, severity of disability and common interventions in pediatric CP patients.</p><p style="text-align: justify;"><strong>METHODS:</strong> CP profile data collection forms were accomplished from September 2014 to December 2015.</p><p style="text-align: justify;"><strong>PRIMARY RESULTS:</strong> Among 125 participants: 55% were < 5 years old, 47% were delivered vaginally, 42% had perinatal onset of condition, 34% had normal birth weight and 23% were moderately preterm. Most were quadriplegic (36%) and spastic (50%). Primary caregivers were mostly mothers (45%) and</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> A hospital-wide cerebral palsy profile should be established to monitor CP, given its multifactorial cause and complex functional impact. Trends should be correlated with maternal and patient factors, healthcare provision and socioeconomics</p>

Legal Aspects of Medical Records / 医学教育

This paper discusses medical records, which are often disputed during lawsuits and play an important role in the factfinding process. There have been no published reports of problems related to medical records or concrete measures to deal with these problems on the basis of a review of judicial precedents. To avoid lawsuits, medical records should be considered in the context of judicial precedents (previous court rulings). The present paper therefore analyzes basic matters related to medical records that were disputed during lawsuits, in relation to judgments obtained in previous court rulings, to determine the judicial role of medical records and their ownership. Although the ownership of medical records is unclear, we believe that patients have some ownership rights over their medical records, that hospitals are responsible for the control of the records, and that physicians have the obligation to use and prepare them. Therefore, medical records can be seen as being jointly owned by the medical care provider and the patient. Analysis of relevant judicial precedents has also allowed us to clarify essential points related to avoiding lawsuits.

Prontuário eletrônico de pacientes: integrando informações clínicas e imagens médicas / Eletronic patient record: integrating clinical information and image data

O Instituto do Coração tem envidado esforços para integrar todas as informações clínicas dentro da Instituição. Nos últimos anos o InCor implementou com sucesso um sistema para transmissão, arquivamento, recuperação, processamento e visualização de Imagens Médicas e um Sistema de Informações Hospitalares (HIS) que armazena as informações administrativas e clínicas. A integração desses subsistemas forma o Prontuário Eletrônico do Paciente (PEP). O InCor é um dos seis Institutos que compõem o Hospital das Clínicas da Universidade de São Paulo. Como cada um dos Institutos possui o seu próprio sistema de informações, a troca de informações entre os Institutos é também uma questão muito relevante. Este trabalho apresenta a experiência no desenvolvimento de um Prontuário Eletrônico funcional e completo, que inclui controle de acesso, exames laboratoriais, imagens (estáticas, dinâmicas e 3D), laudos, documentos e mesmo sinais vitais de tempo real. Este artigo também discute a modelagem e implantação de um protótipo de um PEP distribuído e homogêneo. Atualmente, um volume superior a 2,5 TB de imagens DICOM já foi armazenado utilizando a arquitetura proposta. Diariamente, o PEP armazena mais de 5GB de dados e tem uma quantidade de acessos superior a 300 usuários. O sistema de armazenamento permite uma visibilidade de seis meses para acesso imediato e mais de dois anos para acesso automático utilizando uma jukebox

The Heart Institute (InCor) of São Paulo has been committed to the goal of integrating all clinical information within the institution. In the last few years, InCor has successfully created a system for transmission, archiving, retrieval, processing and visualization of Medical Images and a Hospital Information System (HIS) that stores the institution administrative and clinical information. These integrated subsystems form InCor's Electronic Patient Record (EPR). Since InCor is one of the six institutes of the University of São Paulo Medical School Hospital (HC) and each institute has its own information system, exchanging information among the institutes is also a very important issue. This work describes the experience in the effort to develop a functional and comprehensive EPR, which includes access control, lab exams, images (static, dynamic and 3D), clinical reports, documents and even real-time vital signals. This paper addresses also the design and prototype for integration of distributed and heterogeneous EPR. Currently, more than 2.5 TB of DICOM images, have been stored using the proposed architecture. The EPR stores more than 5 GB/day of data and presents more than 300 hits per day. The proposed storage subsystem allow six months of visibility for rapid retrieval (online mode) and more than two years for automatic retrieval using the jukebox

The application of the computer-based patient record system in hospital information system / 医学研究生学报

Based on the practical running state of the computer-based patient record system in Nanjing General Hospital of Nanjing Military Command,PLA,this paper elaborated the soft structure? function and characteristics of the computer-based patient record system in detail,and the technical implement method of the computer-based patient record system was also introduced in the paper,which has the guidance significance for developing the computer-based patient record system in other hospital.

Utilização do processo de enfermagem em centros de terapia intensiva no Rio de Janeiro como subsídio à implantação de prontuário eletrônico / The nursing process and its application in intensive care at Rio de Janeiro as a support to the development of an electronic patient record

Esse estudo teve por objetivo avaliar a utilização do processo de enfermagem em centros de terapia intensiva na região metropolitana do Rio de Janeiro, de modo a identificar as condições potenciais para a informatização dessas unidades. Foram realizadas entrevistas com 27 enfermeiras líderes de equipe, no período de janeiro a julho de 2003. As entrevistas revelaram que: o processo de enfermagem não era utilizado na íntegra, sistematicamente não incluindo o diagnóstico de enfermagem; 13 centros possuíam formulários de prescrição de enfermagem, mas apenas 11 cederam seus formulários; e 5 centros possuíam algum tipo de sistema informatizado. Dos formulários obtidos, foram identificadas 128 diferentes ações de enfermagem com alta variabilidade de uso e inexistência de padrões para o registro da informação. Diante deste quadro, conclui-se que as condições para a informatização do processo de enfermagem nestes centros não são adequadas.

This study aims at evaluating the utilization of the nursing process in intensive care units in the metropolitan area of Rio de Janeiro, in order to identify the potential conditions for the deployment of a computerized system in those units. Interviews with 27 nursing team leaders were performed in the period from January to July 2003. The interviews revealed that: the nursing process was not fully implemented and not systematically including the nursing diagnostic stage; 13 units had nursing prescription forms, but only 11 released them; and, 5 units used some type of computerized information system. From the forms so obtained, 128 different nursing actions were identified with high variability of use and no existence of standards for data recording. In this scenario, it can be concluded that the conditions for a computerized system for the nursing process are not adequate.

Development of Psychiatric Computerized Medical Records System / 신경정신의학

OBJECTIVES: Computer-based patient record (CPR, Electronic medical record) improves the quality of medical record which reflects the quality of clinical practice. It provides more efficient and convenient way of input, retrieval, storage, communication and management of medical data. The purpose of this study was to develop a practical domestic model and theoretical basis for CPR for psychiatric patients. This model can be applied in other clinical departments. METHODS: The contents and types of items to be included in the data-base were determined through consensus meetings of investigators on the basis of our previous works on the 'comprehensive assessment of symptoms and history in psychiatric disorders' and analysis of structure and items of medical records. The computer program(Asan Medical Center Psychiatric Information System, APIS, version 1.0) was developed using Oracle 7-3-4, Power builder 4.0, Hangul Windows NT and TCP/IP as a programming, development tools, system operation and transmission protocol. RESULTS: The characteristics of APIS are as follows. 1) APIS ensures comprehensive and high quality psychiatric record through combinations of free-text and structured data format and through many available 'help pop-up windows' of required items for better documentations. 2) APIS provides convenient and efficient ways of data input, particularly for narrative input of texts, with various tools such as 'template copy', various 'pop-up lists for block or phrase copy'. 3) APIS enables users to create and modify the template files or scales for research. 4) APIS which adopted principles of POMR (Problem Oriented Medical Record) makes cumbersome management of problem titles very convenient 5) APIS also provides additional statistics necessary for hospital audit and managements as well as mail communication and schedule management of department. 6) Access to APIS requires authorized ID and password where several levels of privileges (view only, edit allowed, master) are assigned to secure the data. And also modification of data was not allowed after completion of medical record except by persons with master ID. User's password and the data before modification can be traced. CONCLUSIONS: Our study results demonstrate the practical model and theoretical basis for CPR for psychiatric patients. We believe that this model and methods contained in this program can also be applied for developments of CPR for other clinical departments.

Cost-Benefit Analysis of the Sharing System for Electronic Patients Records Among Healthcare Institutions / 대한의료정보학회지

In 2000, Korea Health Industry Development Institute(KHIDI) made a plan for sharing electronic patient records between health care institutions which reflects the advance of information technology. The implementation of the plan is believed to have a number of desirable effects such as direct and indirect medical cost savings, the increase in patient satisfaction, the rationalization of health care institution management, and the improvement of health care delivery system. At the same time, however, it requires a great amount of resources for building the system at first and maintaining it since then nationwide. Therefore, the economic evaluation is required for the plan to be undertaken. This paper assessed the plan from economic perspective. In particular, cost-benefit analysis was performed and the result showed that the present value of net benefit, or the social profit is 3,046.3 billion won over the period of 2000-2030. Also, the benefit-cost ratio turned out to be 1.25. The results of cost-benefit analysis confirmed that the benefits of the plan justify the costs.

Economic Analysis of Electronic Patient Record / 대한의료정보학회지

This study was carried out to analyse the economic feasibility of EPR. A hospital with 500 beds under the construction was selected for this study. The economic effect was performed with cost-benefit analysis for 5 years from the year 1998 to 2002. The results of this study were as follows; The economic effect of EPR was classified into direct benefit, value acceleration, and value linking. Each factor was applied and analyzed step by step. In the analysis including only direct benefit, the net present value and the ratio of benefit to cost were minus 82,920,000 won and 0.8. With this traditional cost-benefit analysis alone, the EPR in hospital can be regarded as very unprofitable. However, when value acceleration was added, the net present value and the ratio of benefit to cost rose to 748,637,000 won and 2.7 respectively. Moreover, when value linking was added, the net present value and the ratio of benefit to cost were 1,473,162,000 won and 4.3, respectively. In the results of this study, as EPR has only direct benefit, EPR can be regarded as unprofitable project. However, when value acceleration and value linking were added, EPR can be profitable project.

A development of Entity-Relationship Model on Computer Based Patient Record / 대한의료정보학회지

The purpose of this study presents the model of Entity-Relationship Diagram on CPR. The specific purpose of this study as follows; The first goal is to identify the content and logical structure of the CPR. The second goal is to define the relationship of data coming from diverse systems(for example, clinical laboratory information systems, order entry systems) and the data stored in the CPR. The 22 kinds forms on Medical Record were collected from 10 hospitals. The Clinical heart of the CPR is the core of entities: patient, provider, problem, encounter order, service, history, etc.

AI aided electronic patient records for large intestinal tumors and their management / 中华医院管理杂志

Objective To explore new ways of scientifically collecting and processing clinical information and improve the efficiency of computer management of electronic patient records for large intestinal tumors. Methods An elementalized and standardized analysis and decomposition was made of the information presented by cases of large intestinal tumors and AI aided tabular electronic patient records for large intestinal tumors were designed using the software of Microsoft Access 2000 and compared with the current Word file records. Results A computer management system of electronic patient records for large intestinal tumors was created, with the linkage of the record elements and the electronic tables of the database. Both the speed and quality of patient information input were markedly enhanced. Conclusion AI aided tabular electronic patient records for large intestinal tumors, which are faster and more exact than the Word file records, are beneficial for the speedy input, statistical analysis and AI aided management of clinical information.

Ways of implementing true and practical computer-based patient records / 中华医院管理杂志

Computer based patient records(CPR) are an inevitable trend in the process of building digital hospitals. The authors offer an analysis of the implications and functions of CPR, arguing that in essence computer based patient records are first of all "records", which must carry all the attributes of traditional records and that their "electronic" form of expression and means of implementation are only of secondary importance. The following viewpoints are set forth: ①management of CPR data by means of databases rather than the text mode; ②adoption of authorization by doctors and the scheme of security control; ③implementation of the supplementary subensemble scheme.

Practical digitalized patient records control / 中华医院管理杂志

Objective The objective of digitalized patient records control is to meet some new demands set on patient records control under the new circumstances. Methods A computer system for digitalized patient records control and supporting processing, management and applications setups were established. Results The system put the contents of the patient records into various categories with difierent standards and designed relatively strict means of authorization. It rendered patient records easier to use and their control more strict, making it possible to make general use of the records without access to the original documents. As a result, data loss was avoided, authority over the data was put under control, data sharing was provided, and full and convenient use of data was realized. Conclusion Digitalized patient records control, a form of shaping computer-based patient records before the latter fully comes into being, enhances the efficiency of patient records application and reduces the pressure of paper records storage. It is a practical and effective way of controlling patient records.

Research and development of a computer-based patient record system / 中华医院管理杂志

Objective To research and develop a computer-based patient record (CPR) system so as to realize the collection, processing, storage, transmission and application of patient information. Methods A CPR system was accomplished through developing a structural patient record, a text editor, techniques of database security, a knowledge base of on-line help, real-time monitoring, print control and function expansion. Results The CPR system, established with the above techniques, was put into use in two third-tier hospitals. It was proved via practice that the system, sound in operation, safe and stable, easy to maintain, and compatible, enhanced medical quality and clinical efficiency. Conclusion ①Creating a structural patient record is the basis of realizing CPR. ②Developing a specialized editor is the key to bringing about CPR. ③Possessing perfect database security techniques is the guarantee for starting CPR. ④Constructing a knowledge base of on-line help is an effective way to help doctors raise the level of their clinical decisions. ⑤The CPR system is an effective means of improving the quality of patient records.⑥The CPR system is also an effective means of improving the efficiency of patient record writing.

PKI-based security for computer-based patient record information system / 医疗卫生装备

Public Key Infrastructure (PKI) can provides a series of security services for computer-based patient record information system. This paper discusses the application of PKI to the security of computer-based patient record information system.