One of the important units in the health information system is the electronic medical history. Almost every medical institution is faced with this document; doctors, nurses and extras use it in their activities. In accordance with GOST, the electronic medical history refers to the type of medical documentation on which the quality of care depends.
Why do you need electronic documentation in hospitals?
The predominant part of information systems in the field of healthcare implies the desire for full automation of accounting functions (accounting of services and supplies), 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.
Maintaining an electronic medical history with competent implementation is much easier than the usual paper-based medical records in the understanding of most Russian doctors. This form of documentation has several advantages:
- deprives doctors of the need to do routine "paper" work;
- minimizes the likelihood of medical errors;
- contributes to the improvement of the quality of medical care thanks to versatile expert and analytical capabilities;
- increases the level of patient confidence in the 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 is entitled to receive an extract and any necessary information on hand. To do this, he needs to contact the registry of the medical institution. In addition, from the electronic medical history (GOST R 52636-2006), it is possible to extract the necessary information for accounting, it is important that there are no discrepancies and inconsistencies in the reporting documentation. For example, when the service is paid and mentioned in the accounting department, and nothing is indicated about it in the patient’s medical record.
Health Information Standards in Russia and Abroad
Problems in the field of medical informatization are discussed in our country regularly. Being supporters of the introduction of electronic systems, many experts consider international and European standards as exemplary. Systems for maintaining an electronic medical history are based on the experience and practice of foreign physicians. At the same time, it is difficult to name a country in which the issues of the transition from paper documentation 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 Russia would be wrong to attribute to outsiders in this area. The informatization institutes of the advanced states are still in the starting position, including the United States: here the relevant projects for automating the processing and management of medical documents are at about the same level as our domestic ones.
The implementation of such programs in many respects depends on the national characteristics of the healthcare system; therefore, the adoption of the experience of other powers is not always an expedient and useful solution.
What is a BARS?
An electronic medical history does not exist by itself. You can create such a document as part 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 profile and specialization, the number of branches, medical centers, etc.
This information product involves the creation of functionality for automatic recording of all stages of the diagnostic and treatment process, from pre-appointments to a doctor and issuing an electronic medical record, and ending with document management and financial reporting. The information systems of the 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 history created within the framework of this system is a simple computer program that makes it possible to rationally and efficiently 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 labor of medical staff;
- increasing the level of customer loyalty;
- customer service and the ability to attract new ones;
- quality resource management and patient flow control in order to analyze competitiveness;
- the ability to objectively assess the quality of the 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 get access to 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, a client mode is available through a Web browser that operates in any operating environment (Microsoft Windows, Mac OS, Linux, etc.). The information system itself is built on the principle that IT experts call the basic principle of a three-tier architecture. It includes Oracle database servers and a Web server, as well as a Web browser. This complex provides high reliability of saved data and provides great opportunities for the integration of information.
Users of electronic medical records
Speaking about electronic patient records, one should understand the combination of software and hardware methods and tools that allow you to completely get away from the use of paper media 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 for various reasons will be used for a long time simultaneously with the electronic medical history.
Terms of use of 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 conduct 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 history is intended for several groups of users who pursue various goals.
So, for example, for the administration of the institution, electronic medical records serve as an instrument of operational control over the medical process. Thanks to the introduction of the information base, the head physician, department heads, employees of the department of medical statistics and registry have the opportunity to receive reliable generalized information at any time.
An electronic medical history provides continuous access for ordinary medical staff to detailed information about patients, their medical history, and previous visits. For scientists, medical records are the objects of regular data collection and analysis used in development and research. An electronic case history also plays a role for employees of the planning and economic structures of the institution. A medical card helps you track financial transactions during the medical diagnostic process.
All of the above user groups have their own vision of the role of the electronic medical history, and therefore, they present their requirements for the system implementation process, which often turn out to be contradictory. In this sense, the task of the project managers introducing electronic medical records is to find a reasonable compromise between users at all stages of the development and modernization of the system.
Internal content
What document regulates the structure of the electronic medical history? 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. Key Points. ” The main regulatory act that governs this area of ​​healthcare informatization is the national standard of the Russian Federation “GOST R 52636-2006 Electronic medical history”.
Automated medical records can be classified by the type of information they contain. All information in the patient’s electronic history consists of several parts:
- the formal part, including passport data, nosological form, a general description of the manipulations, the conclusions of consultants, diagnostic doctors, etc .;
- partially formalized information (description of complaints and symptoms, assessment of the general condition of the patient upon admission to the medical facility, results of laboratory tests);
- information that cannot be formalized.
The last category includes a direct history, comments of the attending physician or other narrow-profile specialists about the diagnosis, patient monitoring diaries, and other sections that require a detailed, but not always consistent with any standards description. Moreover, the division into several groups is caused not so much by the amount of information, since for automated processes this factor is not of fundamental importance, but rather the possibility of their consolidation. The electronic medical history template contains the following data:
- information about admission (date and time, initial diagnosis, condition at the time of arrival);
- codes of departments during hospitalization (if the patient uses paid services);
- clinical diagnosis according to the results of the examination;
- date of discharge;
- statistical information;
- information about visits and services provided;
- documentation of initial and control examinations;
- diagnostic results;
- forms of temporary disability sheets;
- protocols of surgical interventions, anesthetic benefits;
- card stay in the intensive care unit.
What are the requirements for electronic medical records
In accordance with GOST 52636-2006, the electronic medical history is not prohibited from being used as a primary medical document. Records on regular observations of the patient, the prescribed diets, prescription sheets, laboratory tests with the results, marks on the perfect manipulations, physiotherapy, massage sessions, exercise therapy, etc. are placed on such a medical record. The written-out epicrisis in most modern clinics is also compiled in electronic mode. From a medical record you can get a statement or certificate much faster.
The medical history in electronic form goes through the mandatory coding stage - this is an automatic update operation in the system of information regarding medical appointments and the patient’s diagnosis. In addition, in a similar mode, the statistical coupon is automatically filled. The use of electronic medical records and related programs, additional subsystems contributes to the final transition to electronic document management inside the clinic, inpatient or other departments of a medical institution.
In accordance with GOST, an electronic medical history must meet a number of requirements. Of particular importance is:
- the availability of all information related to the description of the patient’s health status, previous examinations or treatment;
- guarantee of equal use of the system by patients and medical staff of the medical institution;
- inability to change already entered records in order to protect information from falsification;
- remote access;
- obtaining data for the formation of accounting reports;
- the availability of information that may be required for a specialized examination.
The main problem limiting the maintenance of an electronic medical history is the lack of a clearly developed mechanism for delimiting access and prohibiting retroactive changes to records, as well as the lack of detailed information about each record (who created it and when), poor protection against leakage.
Electronic patient records in clinics
Today, it is known about several models of electronic medical records and a number of programs that are used in medical facilities, including budget hospitals. The clinic is the main place where patient records are generated. Some institutions use the electronic document management model using personal electronic digital signatures of patients, usually wired in a medium (USB key, social card, etc.). In it, data on health insurance can be saved.
The second copy of the electronic signature is stored electronically. The keys are sent to the encrypted storage facility. All specialists and nursing personnel have their own private key on physical media, which provides them with access to an electronic file cabinet. Each entry into the database is fixed, 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 obtain remote access or create a backup copy of the electronic medical history, the base of the medical institution must be synchronized with the federal server, which also provides protection against falsification and falsification of information in hindsight. 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 institution or if hospitalization is required, he needs to take his key and transfer it to the staff of this hospital for temporary storage. This will allow remote access to the main map and new entries. To do this, 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 will be generated for him, which will be used to keep a medical record. At the same time, data must be synchronized with the federal information base every day.
Information leakage risk
In any example of an electronic medical history, information for reports is contained not only in the medical record itself, but also in a separate base of the medical institution. Part of the data about the patient’s visit and appointments is automatically transferred in the form of anonymized information, which can easily determine the number of occupied and free beds, and calculate the percentage of cases of morbidity. Installed triggers provide automatic completion of the diagnosis fields and statement execution.
Knowing only about the general provisions of the electronic medical history, it is not difficult to conclude how convenient it is to use. The attending physician and any narrow specialist who the patient will contact about their 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 certain information on paper. Moreover, the security of the system is ensured even if there is some kind of malfunction in the program: in this case, automatically back up the material. It also provides protection against illegal record variability and information leakage.
At the same time, there are weaknesses in the electronic medical history. In the Order of Rostekhregulirovaniya of December 27, 2006 N 407-Art., Red.dated 01.06.2009), which approved GOST R 52636-2006, there is no clear restriction on the number of possible examinations before a court decision. Today, under standard conditions, several examinations can be made 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
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The information system assumes the use of tools designed for faster text input. Contextual directories are assigned to input fields and provide phrases and terminology that are most common. Thanks to the hierarchical structure of directories, it is possible to construct long phrases. The installation of the standard module of the electronic medical history provides for the inclusion of many directories immediately available for self-supplementing, 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 individual parameters (dosage, duration of treatment, etc.).
Based on the general provisions, an electronic medical history 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 the medical record in the presence of access rights and keys in electronic digital signature format. The most popular MIS "BARS Group" allows you to view patient history 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 input of the same formal information (protocols of operations, observation diaries, preventive medical examinations, etc.).
On the basis of an electronic medical record, the user can generate extracts, certificates, print them out or keep copies of these documents, as well as visually view information about the patient, previous episodes of his illness, get acquainted with expert opinions on the diagnosis, prescription sheets.
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 history allows you to transfer it to any media that can be connected to a computer or other devices for viewing or making edits. In the BARS medical information system, the patient’s electronic medical card module is closely integrated with such system modules as the institution’s financial records, bed capacity, pharmacy, etc.
Completion
The electronic medical history long ago ceased to be considered something strange and outlandish. Today this information tool is used by most medical institutions, many treated 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 hospital workflow, the administration of the institution must set itself phased goals and consistently solve issues related to the use of an automatic information block.
The normative legal act that establishes the rules for maintaining an electronic medical history is an order from the Rostekhregulirovanie. Its publication made it possible to greatly facilitate the work of personnel and automate the process, partially eliminating the need for endless paperwork. The program helps doctors create records, analyze the medical history, terms of treatment and take into account other information contained in previous records of diagnoses, prescribed therapy, complaints, and procedures.