Research software system for electronic health records deployed in hospitals

The Ministry of Health has prescribed the software standard for hospital management software: The establishment, storage and authorization of electron[r]

Research software system for electronic health records deployed in hospitals

Group sciences: Đỗ Thị Tú Uyên

Nguyễn Thị Anh ThuClass: MIS016A

Science advisor: Assoc.Prof Nguyễn Thanh Tùng

1 The necessary of topic

In the medical information system, especially the hospital information system,the storage of patient information, books and paperwork is very important, careful andtime-consuming Large numbers of archival records, such as archives, are too time-consuming, difficult to find, especially information sharing between faculties orhospitals with patients is almost impossible In addition, when the patients go to theexamination must bring old records, papers and medical records are very inconvenientand time consuming for doctors and medical staff to check the health status of thepatient

In Vietnam, technology 4.0 is growing so the birth of electronic medical records

is extremely urgent and practical It makes it easier to diagnose, statistics andscientifically research the specialty, reduce the annual storage of hospital records, andhelp patients and clinicians improve the effectiveness of the clinic treatment andhealth care for patients As a result, nowadays, hospitals in the country have graduallyshifted 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 isvery large, especially in the management of records and keep the data is not a smallnumber In addition, the manual management of medical records has manyshortcomings in the storage, lookup, preservation and confidentiality of information.This is a push for electronic medical records (EMR) to appear EMR makes it easier tostore patient information, doctors and patients better understand the information

In general, the implementation of electronic medical records in Vietnam isinevitable, consistent with the development trend of electronic drugs in the countryand internationally To implement EMR is a process of continuous struggle,persistence and difficulty, must invest many resources We should look at the situation

at home and abroad, the constraints To draw lessons and bring the system toperfection, 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 thisreport:

- 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 ofhospitals in the world such as China, Australia, USA to be able to get a betteroverview of the innovation and development of the medical Old medicalrecords and the problems revolve around it The research team combinesvarious methods such as integrated analysis, descriptive statistics, and so on,through the observations and experiences of each team member, to discuss theadvantages and disadvantages of each Medical records with electronic medicalrecords, causes - actual situation and solutions That is using the comparisonmethod Through the research methodologies and surveyed sites, the researchteam 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, notexpensive 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 mentionelectronic medical records in general and the situation in some hospitals in theNorth 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 andtechnology department, the center for scientific research and the application ofinformation technology Moreover, the new group only visited the technology model

of some hospitals and clinics

Chapter 1: Overview of Electronic Medical Record and Paper

1.1: Paper medical file

"dictionary.com" states: The medical record is "a written document of the length of themedical examination and treatment of a stroke, including a medical history and patientcomplaints., the clinical outcome of the doctor, the results of diagnostic tests andprocedures, drugs and procedures

Medical records are treated as a brochure containing a variety of informationand aspects of the patient From personal information such as name, date of birth,address, living situation, work, to illness, biography, From that, medical recordscan be viewed as There are two main types of patients: primary and secondarypatients In particular, the main disease plays a role directly related to the patient'smedical examination and treatment such as doctor's examination, diagnosis, tests,prescriptions, follow-up examination can also be considered as part of the mainmedical records However, it is closely related to the hospital, not patients such aspersonal information, health insurance, hospital fees, hospital admission procedures,patient support administrative

In summary, medical records are an important part of the hospital informationmanagement system and have important responsibilities in the administrative and

clinical management Accurate, accurate, systematic records will help to make thediagnosis, treatment, prevention, scientific research or training more effective It alsohelps to assess the quality of treatment, morale, responsibility and ability of healthstaff 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 to intensive requirements, may add some necessary contents to the samples afterobtaining the Health Minister's consent

• 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,family guarantee, etc

• Summary of the medical records

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

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

Figure 51: 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 aconfidential information of the patient and cannot be distributed without his or herpermission

• 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 thepatient has signed 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 aredirectly involved 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 aspersonal information of the patient not disclosed

1.1.4: Meaning of medical records

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

• For medical audit and statistical research

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

1.1.4.2: Historical-Scientific Meaning

Systematic records are very important and necessary materials to summarizeand research scientific issues such as diseases, new treatments, new explorationmethods, pathological characteristics A good medical record serves the interests ofdoctors as well as their patients It is very important that the treating doctor properlyrecord the management of the patient under his or her care Thus, medical recordkeeping has evolved into the science

Domestic and international medicine has had different stages of developmentand development with the aim of becoming more complete Because of that, electronicmedical records were born to overcome the limitations of traditional paper medicine

In the era of science-technology development such as dancers, the electronic medicalbirth is inevitable and obey the laws of nature and society

Medical records also have a great historical significance for Vietnamese andworld medicine Because, thanks to the results of the previous ones, thanks to thehistorical studies, medicine will not be as it is today Thanks to that history, we canknow individuals, organizations have great merit in the development of our medicalhistory as Ho Dac Di, Dang Van Ngu, Ton That Tung,

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 collectedfrom functional departments, but this information is often delays, omissions, andmisleading information Forms of paper reports, oral reports, meetings have manylimitations on accuracy and reliability Reporting data is influenced by the sentimentand expertise of the reporter

- 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 the figures when compared Therefore, the hospital leadership cannotfully supervise hospital operations

- Loss of assets, lack of financial transparency: Because each department manages afunction of the hospital, there is no check, collate, verify immediately should occur theloss of property, loss Hospital fees, which are prominent groups of management fees,pharmaceuticals, public assets

Negative: Negative situations cannot be investigated by accidental or intentionalemployees

1.1.5.2 For hospital staff:

- Lack of human resources: Currently, Vietnam lacks human resources for health due

to inadequate training Hospitals are always overloaded

- Human lack of professional quality: Due to busy in overload patients, doctors losethe ability to train themselves due to lack of time, lack of books The knowledge ofdoctors is always old compared to The world's information situation is constantlychanging

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

Figure 52: Difficult of medical paper for hospital staffs

- Waste of storage and retrieval of medical data: Doctors cannot store patient records in

a scientific way Most of the medical records are stored in paper, the contents of therecordings are insufficient Although medical records are stored, it is rarely exploitedfor scientific research

- Waste of information: When examining and treating patients, doctors cannot see themedical history accurately and accurately, especially the way the chronic disease.Therefore, the assessment of the condition will lead to errors There is no memoryfacility, no library system available to support the work The doctor cannot remembereverything, so there is a need for a memory system, a library in place for reference asneeded This helps to improve the value of the doctor's work, which is beneficial to thepatient Para clinical data such as tests; diagnostic imaging are not stored This is thedata warehouse for scientific research

- Waste of time: While doing medical records, medical examination, doctors spend alot of time writing on paper At each stage of the examination, patient informationmust be recorded repeatedly Patients with chronic illnesses who need multipleexaminations should also record administrative details, which can take time

- Harms the patient: Many doctors write hard-to-read prescriptions that make itdifficult for the patient Wrong handwritten bad letters not only help save lives but also

can harm patients because 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 cumbersomeadministrative procedures in patient registration make troublesome for patients Thetime to receive medical services is less than waiting time, loading due toadministrative procedures such as registration, hospital fees, waiting for medicine

Figure 53: 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 Asdoctors lack information about the patient as well as lack of information about thedrug, these patients are taking drugs that are contraindicated and harmful

- Do not get information about your disease: Patients cannot keep their health records

in a consistent, complete way to transfer to another hospital when needed Elderlypatients 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 for monitoring purposes Paper records make it difficult to carrythe records and doctors do not have 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 accurateand incomplete

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

Figure 54: 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 treatmentplan

1.1.5.5 For health insurance policies

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

- The method of calculating the co-payment fee is complicated, making it difficult tocalculate and 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 collectedactually cause many difficulties for accountants.

- The division of drug store into service stores and health insurance holdings increasesthe management 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 accountingpersonnel The reports are frequently deviated from the data, resulting in delinquentsettlements, causing difficulties for hospital operations

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

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

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

1.2: Electronic Medical Record

1.2.1: Birth, definition

Medical records are attached to any person at every visit to health facilities Butnow, it has been replaced by "electronic medical records", meaning that all healthinformation from birth to death is digitized Trends in many developed countries in theworld have been applied in some hospitals in Vietnam, contributing to shortening thetime of medical examination and treatment Medical records are also used by patients

as a method to connect with the doctor The medical records have been amended andsupplemented many times in historical periods to date, but such efforts have not yetbeen able to remove all the burdens that hospitals, administrators, doctors and patientsface Therefore, electronic patients are born with the use and great role to meet theneeds of social development today

Electronic Medical Record (EMR), also known as an online medical recordbook, automates the clinical diagnosis of healthcare facilities The software savespatient's digital prescriptions in a centralized way, allowing physicians to query andretrieve information quickly and accurately A complete electronic health record

includes the patient's demographic tracking functions, medical history, SOAP notes,used drugs, test results and more half.

Electronic medical records (EMRs) are sometimes referred to as electronichealth records (EHS) According to the generally accepted definition, HSI is thepatient's medical history created and stored in a single database Meanwhile, HSBC is

a complete collection of patient records that have been created and stored at variousmedical database sites Due to the technical 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 aftersuccessful implementation:

• 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 onpatient care The speed of treatment of treatment regimens will be faster due to the factthat the medical information is retrieved and accessed conveniently The process ofdelivering and receiving test results from departments and prescribing electronic drugswill be automated with accuracy and speed significantly higher

• Spend more time with the patient

As physicians are freed from a variety of paperwork-related jobs, they spendmore time-saving visits and medical examinations for more patients Cardiology alsoallows doctors to complete medical records faster, thus further increasing theprobability of seeing more patients

• Increase sales of medical practice

Electronic medical records (blood samples, test results, disease codes .)automatically provide physicians with necessary information to complete theprocedures for the payment of health insurance to insurance companies E-M codeidentification (E & M Coding) allows hospital accountants to make billing statementsmore accurately As the speed and quality of work improve, the number of visits willincrease, and the revenue from health care will increase 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, andwarehouse inventory), clinical symptom checkup, and drug interactions check thosehelp doctors prescribe the right medication and correct medications amount TheEBSS software also provides suggestions and solutions for clinicians based on clinicalinformation (symptoms, patient illness history, etc.), or risk factors related to HR Thepatient'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 isindispensable In the current technology 4.0, the birth of electronic medical records is

an inevitable trend and consistent with the era With the presence of technology,electronic medical records have become more and more useful for users such as:

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

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

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

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

With the characteristics listed above, we can imagine how the power of 4.0 technologyhas helped 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 isconsidered the key to successful HIS design Key components of the registrationsystem:

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:Maximum benefits (improved service quality and reduced costs) are really effective

when stakeholders can be comparable Directly interact with information on thesystem Important attributes are:

• Online access (online)

• Supports endpoints

• 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 touse The need for data sharing and functionality among healthcare providers is adriving force behind the need to integrate information across the system to improve theefficiency of HIS Key features 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 standardprocedures for healthcare professionals Provides procedures related to patient careoperations, processing of information and data in medical records

• Use technologies that fully meet user needs and communication between otherapplications on the system: The overall solution to the information infrastructure, dataformats must be modified / updated to suit the purpose and comply with internationalstandards (such as HL7)

• Ensure compatibility and integration with existing legacy systems, and scalability inthe future

• 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 informationsystems that cover all activities and streams of information about hospital managementand treatment And also because of the size and size of the HIS, it is important toconsider splitting the HIS system into independent and supportive subsystems tofacilitate the development and deployment 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 urgentneeds, there have been several hospitals have applied electronic medical recordssystem Most hospitals have only internal software, although quite full, but still not themost convenient Circular 22/2013 / TT-BTTT of the Ministry of Information andCommunications also issued directive that electronic medical records will beuniformly applied from 1/1/2018 However, only five hospitals have been piloted suchas: National Hospital of Pediatrics, Central Hospital for Obstetrics and Gynecology,

Ha Tinh General Hospital, Traditional Medicine, and Hue 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 growthrate (> 16%) of spending on health care, which is also a great potential for promotinge-commerce development According to a survey in 2008 of 4484 doctors in the NewEngland Journal, less than 20% of those doctors used any kind of medical record Theremaining 80% are "bought" but not used Although no country is 100% complete andperfect, 8 developed countries are considered to be the best These are Australia,Canada, Estonia, Denmark, Finland, the Netherlands, Sweden and the United ArabEmirates.

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

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

 HIS

Hospital Informatics System: hospital information management system Theterm is often confused with medical records management (EMR) Hospital informationmanagement is comprehensive, all issues related to hospital information are included

in this terminology HIS includes many things like LIS, RIS, PACS

Figure 55: 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 differentmanufacturers into the PACS system Different devices come with a table that meetsDICOM standards to clarify the service classes that this device supports DICOM hasbeen widely accepted in hospitals and clinics

 HL7

- Define:

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

- Function

For the management of non-visual data, HL7 provides methods for the exchange,management and integration of diagnostic or managed electronic health data HealthLevels 7 is a non-profit organization established in 1987 that is recognized as theworld standard for the exchange, integration, sharing and access of electronic medicalinformation in hospitals as well as health organizations

HL7 creates "interoperability between electronic patient management systems,clinical management systems, laboratory information systems, cafeterias, pharmacies,accounting departments as well as record systems electronic health record (HER) andelectronic medical record (EMR) system HL7 can be provided for free but the license

is quite strict

 LIS

Laboratory Informatics System: laboratory information management system.This system is responsible for receiving designation and returning the designation.Testing information can be directly tapped from the test machine into the informationmanagement system Direct linkage testing can be either 1-way or 2-way One-wayconnection is the direct result from the test machine to the computer Two-waycommunication is to send patient information (PID) from the computer to the testmachine and vice versa, receiving the results from 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 medicalimaging, unlike the laboratory, only resulted in data Today's diagnostic imagingdepartment is developing, not just radiology, but also CT scanners, MRIs, PETs,SPECTs and even hybrid machines

 PACS

- Define:

Picture Achieving Communicating System: As the development of the imagingindustry grows, 3D medical image generation (DICOM standard) is emerging thatrequires a management 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 data transmission facilitates remote diagnostics, diagnosis, treatment, trainingand research, and extends remote viewing and reporting capabilities " Wikipedia:

"PACS is a medical imaging technology that provides economical storage of, andconvenient access to, images from multiple modalities (source machine types)."

• Provides diagnostic functions

• Provides photo-conferencing functionality: between faculty in the hospital andexternal clinics

• Provides video streaming functionality

• Provide ultrasound and endoscopic management program

3.3: Operating Procedures of Electronic Medical Records:

In general, an electronic medical record has a general operational model asfollows:

Figure 56: A general operational model of an electronic medical record

Step 1: Patient is registered at the hospital's reception room and staff is updated withadministrative information for the patient

Step 2: Patient is directed to the clinic by the receptionist

Step 3: Patient will be examined by doctor and laboratory, laboratory Next, thepatient pays a temporary fee and performs a Para clinical indication Then the patientwill have the results

Step 4: Patient will return to the clinic, with subclinical results, the doctor willdiagnose the disease and give the prescription

Step 5: The patient will be paid for the last time at the toll booth, next to the dispensaryand finally to the reception room to receive login information on the hospital portalsystem to review the disease and the results of their diagnosis before returning home

• Electronic medical records review, online consultation

Step 1: Patients log on to the hospital's web site

Step 2: Go to: Electronic Medical Records and view your results at the hospital portal.View medical records: test results, endoscopy, ultrasound, electrocardiogram togetherwith the medication used and the process of treatment, health care of themselves at thehospital

For those who are distant to watch the health of their loved ones in the country canshare the username and password of the patient to see the information

Patients may reprint or back up medical records about personal computers for medicalproof or reference purposes.

3.3.1: Collection and processing of input data

3.3.1.1: Build the database

• Purpose

In the design of the hospital information system (HIS), HIS must be scalable and able

to integrate and communicate with external systems as well as internal hospitalsystems The main functions of an HIS must be able to integrate with otherapplications in the hospital such as patient information systems, patient informationmanagement systems, and financial management systems In addition, HIS must has acentral database system that connects all hospital departmental information systems tostore and provide information or data for all Information systems in the hospital Inthe hospital environment, the central database system supports a variety of purposessuch as medical management, human resources management, patient management, and

so on Because the database center serves multiple purposes and services, the databasemust be thoroughly detailed

• Types:

Includes two types of data (medical data, and patient management data)

Medical data is data related to the patient's disease status, clinical diagnosticdata, laboratory and laboratory outcomes, and patient records; Patient ID data: patientidentification information such as patient name, date of birth, sex, place of birth,ethnicity, etc Patient data of the patient: information This can be changed throughoutthe life of the patient such as the address of the place of residence, work, maritalstatus, etc Medical examination data: Referral information for a hospital visit, such

as ID the amount of medical examination and treatment, the kind of examination andtreatment the patient's financial information including information on medicalexpenses, clinical examination costs, etc.)

Hospital-related data (management information and plan): Also classified intotwo groups (financial data and clinical data) As a patient, clinical and financial dataare generated indirectly to support treatment plans and management functions Clinicaldata is commonly used in clinical monitoring functions Financial data is indispensable

in the course of hospital operations These data are a set of data needed to manage and

operate the hospital's daily operations Incorporating these two types of data willincrease the efficiency of hospital operations and management, and leaders use thisinformation to plan future hospital developments.

• Database management software

The Ministry of Health has prescribed the software standard for hospitalmanagement software: The establishment, storage and authorization of electronicmedical records must comply with the provisions of Article 59 of the Law onExamination and Treatment; Ensure that data / information on patient status isrecorded in electronic records should be in accordance with HL7 standards and inaccordance with the regulations of the Ministry of Health; Make sure medical imagedata / information is compliant with DICOM format; Organizations and individualspermitted to use digital signatures and digital signature certification under the Law onE-Transactions dated November 29, 2005 on digital signatures and digital signaturecertification for electronic medical records; The provision and sharing of information

in e-medical records must ensure the right to respect the privacy of patients asstipulated in Article 8 of the Law on Examination and Treatment and regulations onfiling medical records of the Ministry of Health; Electronic medical records must havethe function of producing summary reports on the medical records when patients havewritten requests as prescribed in Article 11 of the Law on Examination and Treatment.3.3.1.2: Database Input:

With information about patients such as: name, sex, date of birth, ID number,code Automatically calculates the age in years for adults and calculates the child'smonthly age Record contact information: address, email, phone, agency Patientinformation is entered only once in the receiving module Functional units such as theclinic, ultrasound, test will not need to re-enter the patient administrativeinformation

Thanks to the HL7 standard, input data can be entered easily and simply Forexample, a patient named Nguyen Van A, 18, from Hanoi Instead of writing in thetraditional way, now the standard HL7 will be written: Nguyen Van A | 18 | HN Hereuse the "| "Is a distinctive symbol of age, name, and address And the provinces will beabbreviated or coded to reduce the length and save time

Figure 57: Example of Database Input in EMR

3.3.2: Intermediaries and interfaces of HIS with other systems

Figure 58: Intermediaries and interfaces of HIS with other systems

In HIS, CDA / CCD plays the role of the heart of the system, CDA / CCDprovides a model for the exchange of clinical materials such as hospital dischargesummary, referral and delivery of course notes treatment, to achieve an electronicmedical records Furthermore, the standard HIS system will be implemented andimplemented as a pilot system in Vietnam System architecture for HIS system in ahospital This system includes the core database functionality of HIS, HL7 middlewaresupport for HL7 message exchange, DICOM middleware for medical image exchange,web services, and machines application host