Research software system for electronic health records

Hiện nay, các bệnh viện ở Việt Nam vẫn đang sử dụng các bệnh án giấy truyền thống, và mới chỉ có 1 số ít bệnh viện đã sử dụng bệnh án điện tử (electronic medical records). trong bài nghiên cứu khoa học này, tôi có nghiên cứu về bệnh án điện tử cùng công nghệ tiêu chuẩn HL7, DICOM. các bạn thuộc lĩnh vực y tế, công nghệ có thể tham khảo.PSđây là 1 bài nghiên cứu hoàn chỉnh từ az bằng tiếng anh ạ

FINAL REPORTSCIENCE RESEARCH OF STUDENTS

FINAL REPORT SCIENCE RESEARCH OF STUDENTS

Project name:

Research software system for electronic health records deployed in hospitals

Code: 23Group sciences:

Science and technologyResearcher:

ĐỖ THỊ TÚ UYÊNNGUYỄN THỊ THANH THƯ

Class:

MIS2016AProgram:

Management Information System

Science advisor:

Assoc.Prof NGUYỄN THANH TÙNG

Hanoi, May 1, 2018

VIETNAM NATIONAL UNIVERSITY, HANOI

INTERNATIONAL SCHOOL

Form 03

LIST OF STUDENT PARTICIPATION IN RESEARCH

Place of Birth : Ha Nam

Class : MIS2016A Course : 15

Addrest: Trinh Xa, Phu Ly City, Ha Nam provine

Phone : 0919500641 Email : dothituuyen98hn@gmail.com

II STUDY PROCESS (declaration of student achievement from year 1 to now):

* First year :

Programme : Management Information System School : IS_VNU Graded learning outcomes : Academic pretty

Summary Achievements:

 Achieves the scholarship of school

 GPA scores are good

 Participante in mass activities organized by school

 Participante in social activities such as charity, Blood donation,

* Second year : (unfinished)

Place of Birth : Ha Nam

Class : MIS2016A Course : 15

Address: Thanh Liem, Ha Nam provine

Phone : 01636477106 Email : thanhthu2010ts@gmail.com

II STUDY PROCESS (declaration of student achievement from year 1 to now):

* First year :

Programme : Management Information System School : IS_VNU

Graded learning outcomes : Academic pretty

Summary Achievements:

 Achieves the scholarship of school

 GPA scores are good

 Participante in mass activities organized by school

 Participante in social activities such as charity, Blood donation,

* Second year : (unfinished)

Host Institution Officer of Research and Partnership

Development

Student mainly responsibility of research

(signed and full name)

INFORMATION OF THEMES RESULTS

1 General information:

- Topic: Research software system for electronic health records deployed in hospitals

- Researcher: Đỗ Thị Tú Uyên

Nguyễn Thị Thanh Thư

- Class: MIS2016A Program: MIS Year: 2016 Years of training: 4 years

- Science advisor: Nguyễn Thanh Tùng

2 The goal of topic:

On purpose, electronic medical records help to connect patient data from multiple sources and to provide applications and data so patients can understand and improve their health as well as help doctors access and follow up information of patients It also helps to investigate responsibility for problems arising from something In summary, electronic

medical records help physicians and patients to be more proactive in protecting their health and diagnosing illness anywhere

3 The novelty and creation:

If the medical paper still has a lot of difficulties, now the electronic medical records have overcome almost all this disadvantages This technology is no stranger in the world but quite new when applied in the field of health in Vietnam This technology allows storage of a huge data volume and can be accessed anytime, anywhere, while ensuring the security of data

4 Research outcomes:

Learn the causes, current status, pros - cons and solutions for electronic medical records Learn about the medical market and suppliers in the country and in the world In addition, we also investigated how an electronic medical record system works and how to put

it into practice Based on the fact, draw the fault of the hospital has been to improve electronicmedical records on a better We have also improved our understanding as well as shared the results of this research for everyone to know

5 Practical contributions:

Applying information technology in the medical network is very important Medical

standards such as DICOM for medical images and HL7 (health level 7) standards for data

exchange The urgent need for a private network for health is inevitable According to the

library's bookcase catalog, the standard for health information exchanges was developed by

HL7 in 1987 with the first version After that, versions 2.0 and 3.0 are released and are

currently being updated and developed For the 3x version, research in the world has built

hundreds, thousands of newsletters, built the data formats as well as updated the reference

model for HL7 With this standard structure, the characteristic health network allows each

patient to have a complete record of all pathological and pathological profiles, prohibitions forprescribing medication, and so on This gives the patient clear information to better manage

his or her health

6 Scientists publication of the student research results or comments, evaluate of the

establishments have applied the research results (If available):

Hanoi, Date: 20/04/2018

Reviews of instructor on the scientific

contributions of students to implement

the research (This section is recorded by

NGUYỄN THỊ THANH THƯ

Table of contents

List of student in research……….……… ….3

Information of student……… ….4

Information of them result……….………6

Table of figures……….……… 10

Declaration…… ……….……….….11

Acknowledgements……… 12

Introduction……….13

Chapter 1: Overview of Electronic Medical Record and Paper……… 15

1.1: Paper medical file ……….15

1.1.1 Definition……….15

1.1.2: Features……… 15

1.1.2.1: History of the formation……….……….15

1.1.2.2: Basic structure……….16

1.1.3: Access to medical records……….………17

1.1.4: Meaning of medical records……… 17

1.1.4.1: practical meanings……….………….17

1.1.4.2: Historical-Scientific Meaning……….……….18

1.1.5 Difficult of medical paper………18

1.1.5.1 For hospital leaders……….……….18

1.1.5.2 For hospital staff……….19

1.1.5.3 For patients……….……….….20

1.1.5.4 For health reporting system - statistics - disease test……….……….……21

1.1.5.5 For health insurance policies……….….….21

1.2: Electronic Medical Record ……….…….….22

1.2.1: Birth, definition……….22

1.2.2 Overview of utility, properties of electronic medical records………23

1.2.3: Technology with Electronic Medical Record……… ….24

1.2.3: Factors that an electronic medical record must have……….24

1.2.4: Conditions for implementing an electronic medical record……….……….26

Chapter 3: The Emergence of Electronic Medical Record and how it works, its role………27

3.1: Situation at home and abroad……….27

3.2: Parts of an electronic medical record and their concepts……….………….27

3.3: Operating Procedures of Electronic Medical Records……….……….31

3.3.1: Collection and processing of input data……….32

3.3.1.1: Build the database………32

3.3.1.2: Database Input……….34

3.3.2: Intermediaries and interfaces of HIS with other systems……… ….……35

3.3.3: Export outputs and medical record keeping……….………….…… ….44

3.3.3.1: Output……….… …44

3.3.3.1.1: Receipt - charge - Health insurance……….……… ….…44

3.3.3.1.2: Clinic module……….……,.….45

3.3.3.1.3: Image Diagnostics Subsystem……….… ….46

3.3.3.1.5: Outpatient Pharmacy……… … ….46

3.3.3.1.6: Residential management module……… ….46

3.3.3.1.7: Hospital pharmacy management system……… ….… ….47

3.3.3.1.8: Reporting - statistics - data mining……….…….….…48

3.3.3.2: Storage and Preservation……….………… …48

3.3.3.3: Situation of collecting electronic medical records into archives….……… …48

3.3: Advantages and Disadvantages of Electronic Diseases……….………… …50

3.3.1: Advantages……… ….……….……50

3.3.2: Limitations……….…….……53

Chapter 4: Comprehensive Solution and Enhance Efficiency in the Storage and Management of Electronic Medical Record……….……….55

Conclusion and Recommendation………57

References……….59

Appendices……… ……….62

Table of Figures

FIGURE 1: DIAGRAM OF THE FORMING A GENERIC MEDICAL RECORD

FIGURE 2: DIFFICULT OF MEDICAL PAPER FOR HOSPITAL STAFFS

FIGURE 3: DIFFICULT OF MEDICAL PAPER FOR PATIENTS

FIGURE 4: DIFFICULT OF MEDICAL PAPER FOR HEALTH REPORTING SYSTEM - STATISTICS - DISEASE TEST FIGURE 5: FUNCTION OF HIS

FIGURE 6: A GENERAL OPERATIONAL MODEL OF AN ELECTRONIC MEDICAL RECORD

FIGURE 7: EXAMPLE OF DATABASE INPUT IN EMR

FIGURE 8: INTERMEDIARIES AND INTERFACES OF HIS WITH OTHER SYSTEMS

FIGURE 9: DOCTORS CAN ACCESS ONLINE

FIGURE 10: DOCTORS CAN EASILY MANAGE PATIENTS UNDERGOING TREATMENT 1

FIGURE 11: DOCTORS CAN EASILY MANAGE PATIENTS UNDERGOING TREATMENT 2

FIGURE 12: TYPICAL HOSPITAL IT SYSTEMS

FIGURE 13: THE LIST OF PATIENTS IN SYSTEM

FIGURE 14: SYSTEM OF DICOM STANDARD

FIGURE 15: THE RELATIONSHIP OF RIS AND PACS

FIGURE 16: SUBCLINICAL INFORMATION FOR A PATIENT

FIGURE 17: PACS SYSTEM

FIGURE 18: DICOM FILE FORMAT

FIGURE 19: HOSPITAL FEES

FIGURE 20: MEDICINE MANAGEMENT FOR A PATIENT

Declaration

I pledge that:

The data in the dissertation is truthfully investigated

We are responsible for our research

After studying and training at the International School - Vietnam National University with gratitude and respect, we would like to express our sincere thanks to the Board of Directors, Departments, Faculty of International School -Vietnam National University and the teachers have been enthusiastic in teaching, and facilitating our learning, research and completion of this research topic

In particular, I would like to express my deep gratitude to Mr Nguyen Thanh Tung, who taught me directly and assisted me during the project implementation

Sincerely thank family, friends have created close conditions, learning to complete this topic

However, our own capacity is still limited, the subject of scientific research is certainly the inevitable shortcomings We would like to receive feedback from our teachers and friends so that our research can be improved

Thank you,

Hanoi, May 1, 2018

Researcher: ĐỖ THỊ TÚ UYÊN & NGUYỄN THỊ THANH THƯ

Science advisor: Assoc.Prof NGUYỄN THANH TÙNG

1 The necessary of topic

In the medical information system, especially the hospital information system, thestorage of patient information, books and paperwork is very important, careful and time-consuming Large numbers of archival records, such as archives, are too time-consuming,difficult to find, especially information sharing between faculties or hospitals with patients isalmost impossible In addition, when the patients go to the examination must bring oldrecords, papers and medical records are very inconvenient and time consuming for doctorsand medical staff to check the health status of the patient

In Vietnam, technology 4.0 is growing so the birth of electronic medical records isextremely urgent and practical It makes it easier to diagnose, statistics and scientificallyresearch the specialty, reduce the annual storage of hospital records, and help patients andclinicians improve the effectiveness of the clinic treatment and health care for patients As aresult, nowadays, hospitals in the country have gradually shifted to the collection and storage

of electronic medical records

2 The goal of topic

Health care is a matter of concern in this day However, the annual cost for it is verylarge, especially in the management of records and keep the data is not a small number Inaddition, the manual management of medical records has many shortcomings in the storage,lookup, preservation and confidentiality of information This is a push for electronic medicalrecords (EMR) to appear EMR makes it easier to store patient information, doctors andpatients better understand the information

In general, the implementation of electronic medical records in Vietnam is inevitable,consistent with the development trend of electronic drugs in the country and internationally

To implement EMR is a process of continuous struggle, persistence and difficulty, must investmany resources We should look at the situation at home and abroad, the constraints To drawlessons and bring the system to perfection, apply it to the real world soon

3 Research questions, methodology and scope of research

 Research questions:

In general, we have followed a few key questions below to make this report:

- What is electronic medical records?

- What is situation of electronic medical records at home and abroad?

- What are advantages and disadvantages of electronic medical records?

- How difficult and how to overcome?

 Methodology:

Firstly, the research team studied many documents on the network of hospitals

in the world such as China, Australia, USA to be able to get a better overview of theinnovation and development of the medical Old medical records and the problems revolve around it The research team combines various methods such as integrated analysis, descriptive statistics, and so on, through the observations and experiences of each team member, to discuss the advantages and disadvantages of each Medical records with electronic medical records, causes - actual situation and solutions That isusing the comparison method Through the research methodologies and surveyed sites,the research team can draw on the experience of paper medical records and how EMR can be put into operation, so that it can bring many benefits to the people, not

expensive but modern and catch up the trend of the world

 Sphere of analysis:

Due to time constraints as well as busy learning, here we only mention electronic medical records in general and the situation in some hospitals in the North

as a number overseas hospitals through the internet

4 Facilities and the difficulty of the researching process

4.1 Facilities

At present, the research team uses only the facilities of the science and technologydepartment, the center for scientific research and the application of information technology.Moreover, the new group only visited the technology model of some hospitals and clinics

4.2 Difficulty

Firstly, the research time is limited and due to busy learning, the group cannot studydeeply about the topic Secondly, the physical facilities for research are limited In addition,the group also had limited access to hospitals In other words, the scope of the research group

is limited and mainly referred to through the media, television, internet, etc

Chapter 1: Overview of Electronic Medical Record and Paper.

1.1: Paper medical file

"a written document of the length of the medical examination and treatment of a stroke,including a medical history and patient complaints., the clinical outcome of the doctor, theresults of diagnostic tests and procedures, drugs and procedures

Medical records are treated as a brochure containing a variety of information and aspects ofthe patient From personal information such as name, date of birth, address, living situation,work, to illness, biography, From that, medical records can be viewed as There are twomain types of patients: primary and secondary patients In particular, the main disease plays arole directly related to the patient's medical examination and treatment such as doctor'sexamination, diagnosis, tests, prescriptions, follow-up examination can also be considered

as part of the main medical records However, it is closely related to the hospital, not patientssuch as personal information, health insurance, hospital fees, hospital admission procedures,patient support administrative

In summary, medical records are an important part of the hospital information managementsystem and have important responsibilities in the administrative and clinical management.Accurate, accurate, systematic records will help to make the diagnosis, treatment, prevention,scientific research or training more effective It also helps to assess the quality of treatment,morale, responsibility and ability of health staff in particular and the hospital in general

1.1.2: Features

1.1.2.1: History of the formation

Decision No 4069/2001 / QD-BYT, September 28, 2001, of the Ministry of Healthpromulgating forms of dossiers for medical examination and treatment establishments(collectively referred to as hospitals) public, private, private, foreign-invested medicalexamination and treatment establishments Particularly leading specialized hospitals, due tointensive requirements, may add some necessary contents to the samples after obtaining theHealth Minister's consent

1.1.2.2: Basic structure

There are 24 medical records for general hospitals Each type has its own structure butbasically consists of the main parts such as:

• Medical records

The size is 27x53 cm The front of the cover shows the patient information as well as the type

of illness and some information at the doctor's visit The back cover is medical records

• Documents and contents inside the medical record

Include a general information about the patient, the status of the examination, theadministrative papers, the results of the test, the standard meeting card, treatment card, familyguarantee, etc

• Summary of the medical records

The important thing is that all the papers inside the medical records must have the signature,title, and seal of the people involved in the disease Especially the primary physician

We can refer to the process of forming a medical record set by the Ministry of Health:

Figure 1: Diagram of the forming a generic medical record

1.1.3: Access to medical records

The question is: Who has the right to see the medical records?

• A medical record is the property of the hospital or the physician This is a confidentialinformation of the patient and cannot be distributed without his or her permission

• All patients have access to their records and get copies of those records

• The legal representative of the patient has the right to such records as long as the patient hassigned a notice with the request of the representative at law

• Other health care providers have the right to keep a record of the patient if they are directlyinvolved in the care and treatment of the patient

• Parents of minors also have access to patient records

• Medical records are often called in court in some cases such as road traffic accidents,medical malpractice, insurance claims

• Personal documents used for research purposes require patient consent as well as personalinformation of the patient not disclosed

1.1.4: Meaning of medical records

Due to the above characteristics, medical records have important and irreplaceable meanings.These basic meanings are:

1.1.4.1: practical meanings

Because medical records have a direct relationship to human health, it has a great significance

in the real world Some typical meanings are:

• Real patient monitoring

• Medical research

• Medical education

• For insurance, personal injury, employee compensation, a criminal case, case

• For litigation

• For medical audit and statistical research

In addition, medical records reflect the relationship between the physician and the patientduring the course of treatment is recorded in the medical record The attitudes, behaviors, andsatisfaction of patients with the hospital can be assessed

1.1.4.2: Historical-Scientific Meaning

Systematic records are very important and necessary materials to summarize and researchscientific issues such as diseases, new treatments, new exploration methods, pathologicalcharacteristics A good medical record serves the interests of doctors as well as their patients.

It is very important that the treating doctor properly record the management of the patientunder his or her care Thus, medical record keeping has evolved into the science

Domestic and international medicine has had different stages of development anddevelopment with the aim of becoming more complete Because of that, electronic medicalrecords were born to overcome the limitations of traditional paper medicine In the era ofscience-technology development such as dancers, the electronic medical birth is inevitableand obey the laws of nature and society

Medical records also have a great historical significance for Vietnamese and world medicine.Because, thanks to the results of the previous ones, thanks to the historical studies, medicinewill not be as it is today Thanks to that history, we can know individuals, organizations havegreat merit in the development of our medical history as Ho Dac Di, Dang Van Ngu, Ton ThatTung,

Therefore, it can be reassured that medical records are extremely important and that nodocument can be replaced

1.1.5 Difficult of medical paper:

1.1.5.1 For hospital leaders:

- Incorrect information: Hospital management is dependent on information collected fromfunctional departments, but this information is often delays, omissions, and misleadinginformation Forms of paper reports, oral reports, meetings have many limitations onaccuracy and reliability Reporting data is influenced by the sentiment and expertise of thereporter

- Inadequate information: The hospital's activities are now reflected in discrete, incomplete,interlinked reports Most of the reported data coming from different parts do not match thefigures when compared Therefore, the hospital leadership cannot fully supervise hospitaloperations

- Loss of assets, lack of financial transparency: Because each department manages a function

of the hospital, there is no check, collate, verify immediately should occur the loss ofproperty, loss Hospital fees, which are prominent groups of management fees,pharmaceuticals, public assets

Negative: Negative situations cannot be investigated by accidental or intentional employees

1.1.5.2 For hospital staff:

- Lack of human resources: Currently, Vietnam lacks human resources for health due toinadequate training Hospitals are always overloaded.

- Human lack of professional quality: Due to busy in overload patients, doctors lose the ability

to train themselves due to lack of time, lack of books The knowledge of doctors is alwaysold compared to The world's information situation is constantly changing

- Waste of professional staff: Doctors are trained in medical specialty but must doadministrative work Administrative work is an unprofessional work for the doctor, whichlimits the effectiveness of administrative work and the loss of professional competence.Reporting data always takes a lot of time and effort to the doctor

Figure 2: Difficult of medical paper for hospital staffs

- Waste of storage and retrieval of medical data: Doctors cannot store patient records in ascientific way Most of the medical records are stored in paper, the contents of the recordingsare insufficient Although medical records are stored, it is rarely exploited for scientificresearch

- Waste of information: When examining and treating patients, doctors cannot see the medicalhistory accurately and accurately, especially the way the chronic disease Therefore, theassessment of the condition will lead to errors There is no memory facility, no library systemavailable to support the work The doctor cannot remember everything, so there is a need for amemory system, a library in place for reference as needed This helps to improve the value ofthe doctor's work, which is beneficial to the patient Para clinical data such as tests; diagnosticimaging are not stored This is the data warehouse for scientific research

- Waste of time: While doing medical records, medical examination, doctors spend a lot oftime writing on paper At each stage of the examination, patient information must be recorded

repeatedly Patients with chronic illnesses who need multiple examinations should also recordadministrative details, which can take time.

- Harms the patient: Many doctors write hard-to-read prescriptions that make it difficult forthe patient Wrong handwritten bad letters not only help save lives but also can harm patientsbecause of the wrong medication or use the wrong way Prescriptions are not contraindicated;drug interactions will also harm the patient

1.1.5.3 For patients:

- Many troubles in medical examination and treatment: The cumbersome administrativeprocedures in patient registration make troublesome for patients The time to receive medicalservices is less than waiting time, loading due to administrative procedures such asregistration, hospital fees, waiting for medicine

Figure 3: Difficult of medical paper for patients

Negative: When procedures are difficult for the patient, there is a negative relationshipbetween the patient and the healthcare provider Victims, hooks occur in many places

- Medical harm: Patients with special conditions such as allergies, pregnancy, lactation,children or special diseases should avoid using potentially harmful drugs As doctors lackinformation about the patient as well as lack of information about the drug, these patients aretaking drugs that are contraindicated and harmful

- Do not get information about your disease: Patients cannot keep their health records in aconsistent, complete way to transfer to another hospital when needed Elderly patients with

chronic diseases such as hypertension, diabetes or special diseases such as mental illness,kidney failure, cancer are often required to keep records in a synchronous manner formonitoring purposes Paper records make it difficult to carry the records and doctors do nothave much time to see the full course of the disease.

1.1.5.4 For health reporting system - statistics - disease test:

- The hospital statistics used to report to the above management levels are not accurate andincomplete

- The manual reporting of the paper takes a lot of time

Figure 4: Difficult of medical paper for health reporting system statistics disease test

- (Internet photos)

- There are too many types of reports, statistics to do, repeat

- When epidemics arise, the data does not show immediately to have a treatment plan 1.1.5.5 For health insurance policies

The State of Vietnam is implementing the health insurance policy, moving towards universalhealth insurance by 2014 In the past years, the implementation of the health insurance lawhas caused many problems, so far has not been resolved decisive:

- The method of calculating the co-payment fee is complicated, making it difficult to calculateand determine the hospital fee for each patient

- The management and preservation of prescriptions to verify when finalization reportincreases work for doctors and consume ink as well as archives

- Formulas for calculating health service packages that are not actually collected actuallycause many difficulties for accountants.

- The division of drug store into service stores and health insurance holdings increases themanagement of pharmaceuticals and difficulties in the supply of drugs

- Problems of child health insurance and accident cases are unclear

- Quarterly statement-making difficult, takes much time and effort of accounting personnel.The reports are frequently deviated from the data, resulting in delinquent settlements, causingdifficulties for hospital operations

- Health insurance reporting requirements change frequently, making it difficult to report data

- There is also the problem of abuse of health insurance card of patients and medical staff,deliberately misrepresentation to receive drug causing loss to the health insurance budget.This has happened in many places and there are no effective preventive measures

- The troublesome administration of health insurance gives patients the difficulties of medicalexamination make the patient look aversion

1.2: Electronic Medical Record

to date, but such efforts have not yet been able to remove all the burdens that hospitals,administrators, doctors and patients face Therefore, electronic patients are born with the useand great role to meet the needs of social development today

Electronic Medical Record (EMR), also known as an online medical record book, automatesthe clinical diagnosis of healthcare facilities The software saves patient's digital prescriptions

in a centralized way, allowing physicians to query and retrieve information quickly andaccurately A complete electronic health record includes the patient's demographic trackingfunctions, medical history, SOAP notes, used drugs, test results and more half

Electronic medical records (EMRs) are sometimes referred to as electronic health records(EHS) According to the generally accepted definition, HSI is the patient's medical historycreated and stored in a single database Meanwhile, HSBC is a complete collection of patientrecords that have been created and stored at various medical database sites Due to thetechnical differences between the two concepts

1.2.2 Overview of utility, properties of electronic medical records

The following are the minimum benefits provided by the software after successfulimplementation:

• Improve the effectiveness of medical practice

Treatment management and treatment will be rationalized at the highest level Indeed,cumbersome paperwork is eliminated, leaving doctors more time to focus on patient care Thespeed of treatment of treatment regimens will be faster due to the fact that the medicalinformation is retrieved and accessed conveniently The process of delivering and receivingtest results from departments and prescribing electronic drugs will be automated withaccuracy and speed significantly higher

• Spend more time with the patient

As physicians are freed from a variety of paperwork-related jobs, they spend more saving visits and medical examinations for more patients Cardiology also allows doctors tocomplete medical records faster, thus further increasing the probability of seeing morepatients

time-• Increase sales of medical practice

Electronic medical records (blood samples, test results, disease codes .) automaticallyprovide physicians with necessary information to complete the procedures for the payment ofhealth insurance to insurance companies E-M code identification (E & M Coding) allowshospital accountants to make billing statements more accurately As the speed and quality ofwork improve, the number of visits will increase, and the revenue from health care willincrease This is one of the top benefits of electronic medical records

• Improve the quality of patient care

Features include a drug database (prescription management, drug, and warehouse inventory),clinical symptom checkup, and drug interactions check those help doctors prescribe the rightmedication and correct medications amount The EBSS software also provides suggestionsand solutions for clinicians based on clinical information (symptoms, patient illness history,etc.), or risk factors related to HR The patient's diet This is one of the remarkable advantages

of electronic health records

1.2.3: Technology with Electronic Medical Record

Electronic medical treatment is a process of continuous struggle, persistence, difficulty, have

to invest many resources Therefore, information technology is indispensable In the currenttechnology 4.0, the birth of electronic medical records is an inevitable trend and consistentwith the era With the presence of technology, electronic medical records have become moreand more useful for users such as:

• Standardization of the general list currently used in e-medical software under the Ministry ofHealth and the competent authorities;

• Apply national and international standards to ensure interconnection, exchange of databetween LIS and HIS software and testing facilities and equipment;

• Apply HL7 and DICOM standards to ensure interoperability, exchange of diagnostic databetween RIS / PACS with HIS software and imaging equipment

• HIS, LIS, RIS / PACS software provides complete data/information for EMR software (HL7CDA, Clinical Documentation Architecture (HL7 CDA)) interconnect, exchange clinical datawith other medical software

With the characteristics listed above, we can imagine how the power of 4.0 technology hashelped the health sector in particular and other areas of society in general

1.2.3: Factors that an electronic medical record must have:

General registration function for all patient information: Data collection is considered the key

to successful HIS design Key components of the registration system:

Patient data from birth to death

Maintaining data from start to finish

Character data, images, sounds, signals, digital data

Electronic medical records allow access to information from anywhere at any time: Maximumbenefits (improved service quality and reduced costs) are really effective when stakeholderscan be comparable Directly interact with information on the system Important attributes are:

• Online access (online)

• Support doctors in the clinic

• Outpatient clinical information support

• Extract information, and support wireless devices

Recognizing that healthcare providers are primary users, applications must be easy to use Theneed for data sharing and functionality among healthcare providers is a driving force behindthe need to integrate information across the system to improve the efficiency of HIS Keyfeatures include:

A user interface should be simple, easy to use

• Functions must be complete

• Provides a variety of information retrieval methods on the system

• Access to other data facilities

• Provide expert systems

• Provide data conversion tools to information

• HIS must be cost-effective

• Open system design

• Use international standards

• Design effective

• Design by modules

• Leverage available hardware and software

• Provide communication between the hospital and HIS systems: Provide standard proceduresfor healthcare professionals Provides procedures related to patient care operations, processing

of information and data in medical records

• Use technologies that fully meet user needs and communication between other applications

on the system: The overall solution to the information infrastructure, data formats must bemodified / updated to suit the purpose and comply with international standards (such as HL7)

• Ensure compatibility and integration with existing legacy systems, and scalability in thefuture

• Ensure attributes such as:

1) ability to respond, respond quickly,

2) High availability and reliability,

3) Confidentiality and integrity of data/information

The suggested general architecture of HIS HIS includes child information systemsthat cover all activities and streams of information about hospital management and treatment.And also because of the size and size of the HIS, it is important to consider splitting the HISsystem into independent and supportive subsystems to facilitate the development anddeployment of HIS Sy

1.2.4: Conditions for implementing an electronic medical record:

• Having an intranet;

• Having an operating electronic medical record server;

• Have a database server (database) to store the records;

There are workstations at each department or department;

• Have IT, staff;

• Employees involved in electronic medical records must be skilled

• IT capabilities;

• Have a system of safety, security and data confidentiality; stem

Chapter 3: The Emergence of Electronic Medical Record and how it works, its role.

3.1: Situation at home and abroad

Currently in Vietnam, with favorable technological development and urgent needs,there have been several hospitals have applied electronic medical records system Mosthospitals have only internal software, although quite full, but still not the most convenient.Circular 22/2013 / TT-BTTT of the Ministry of Information and Communications also issued

only five hospitals have been piloted such as: National Hospital of Pediatrics, CentralHospital for Obstetrics and Gynecology, Ha Tinh General Hospital, Traditional Medicine, andHue Central Hospital However, it is still in the deployment and completion phase.

Unlike our country, friends in Europe have had and deployed electronic medicalrecords for a long time, and now it is as stormy The world has a significant growth rate (>16%) of spending on health care, which is also a great potential for promoting e-commercedevelopment According to a survey in 2008 of 4484 doctors in the New England Journal, lessthan 20% of those doctors used any kind of medical record The remaining 80% are "bought"but not used Although no country is 100% complete and perfect, 8 developed countries areconsidered to be the best These are Australia, Canada, Estonia, Denmark, Finland, theNetherlands, Sweden and the United Arab Emirates

3.2: Parts of an electronic medical record and their concepts:

An electronic medical record consists of a number of different usages and functions, however, in here, we only focus on a number of data standards Let's take a look at some of the important data standards used in it

 HIS

Hospital Informatics System: hospital information management system The term is oftenconfused with medical records management (EMR) Hospital information management iscomprehensive, all issues related to hospital information are included in this terminology HISincludes many things like LIS, RIS, PACS

Figure 5: Function of HIS

- Function:

The DICOM standard allows for easy integration of image receivers, servers, workstations,printers, and other hardware devices that are networked from different manufacturers into thePACS system Different devices come with a table that meets DICOM standards to clarify the

service classes that this device supports DICOM has been widely accepted in hospitals andclinics.

According to nanosoft.vn, the name HL7 is derived from the communication model of ISO 7.Each layer has a role in which Layer 1 to Layer 4 refers to communications, includingPhysical, Datalinks, Network, and Transport Grades 5-7 refer to functions such as Session,Presentation and Application Layer 7 is the highest class that refers to the application levelincluding the concepts of data exchange This level supports a variety of functions such assecurity checks, participant identification, data exchange structures, etc

as well as health organizations

HL7 creates "interoperability between electronic patient management systems, clinicalmanagement systems, laboratory information systems, cafeterias, pharmacies, accountingdepartments as well as record systems electronic health record (HER) and electronic medicalrecord (EMR) system HL7 can be provided for free but the license is quite strict

 LIS

Laboratory Informatics System: laboratory information management system Thissystem is responsible for receiving designation and returning the designation Testinginformation can be directly tapped from the test machine into the information managementsystem Direct linkage testing can be either 1-way or 2-way One-way connection is the directresult from the test machine to the computer Two-way communication is to send patientinformation (PID) from the computer to the test machine and vice versa, receiving the resultsfrom the test machine to the computer

 RIS

Radiology Informatics System: X-ray information management system Previously,the RIS term was used because the radiology department for medical imaging, unlike thelaboratory, only resulted in data Today's diagnostic imaging department is developing, notjust radiology, but also CT scanners, MRIs, PETs, SPECTs and even hybrid machines

 PACS

Picture Achieving Communicating System: As the development of the imagingindustry grows, 3D medical image generation (DICOM standard) is emerging that requires amanagement and imaging system

PACS: A system for receiving, storing, processing and transmitting multimediamedical data to improve the efficiency of medical examination and treatment MilitaryMedical Academy: "PACS is used for safe and economical image data archiving; Image datatransmission facilitates remote diagnostics, diagnosis, treatment, training and research, andextends remote viewing and reporting capabilities " Wikipedia: "PACS is a medical imagingtechnology that provides economical storage of, and convenient access to, images frommultiple modalities (source machine types)."

• Provides diagnostic functions

• Provides photo-conferencing functionality: between faculty in the hospital and externalclinics