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“Evaluate HSJ-ICU system use by medical doctors”. Professor Orientador: Ricardo Correia. Turma 20. Introduction. Formulate diagnosis hypotheses Decide the therapeutical treatment. It’s important to:. Medical record. Set of documents Clinical data Clinical history
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“Evaluate HSJ-ICU system use by medical doctors” Professor Orientador: Ricardo Correia Turma 20
Formulate diagnosis hypotheses • Decide the therapeutical treatment It’s important to: Medical record • Set of documents • Clinical data • Clinical history • Physical examination • Diagnosis and treatments • Laboratorial tests • Complementary reports of diagnosis • Other notes made by health professionals • Administrative data [1]
Paper Medical Records Electronic Medical Records [2]
Paper Medical Record (PMR) • Advantages: • Familiar to users • Easily transportable • Do not experience downtime as computer systems do • Flexibility [2]
Electronic Medical Records (EMR) They are more than single computerization of PMR [5] • Advantages: • Various forms of viewing and analysing the information • Frequently up-dated • Lesser losses and duplicity of information • Legibility • Consistencie of information (format and localization) • Internal structure • Help in the management of medical resources • Support medical investigation and education • Share information • The acess is restricted [4] [1] [6] [1]
Administrative data • General clinical information (SAM – Sistema de Apoio ao Médico) • Reduced flexibility • Lack of specification • Unrelated DIS • Duplicated data Implementation of different Departamental Information Systems (DIS) Share of clinical information using PMR High administrative costs (time and staff) In Hospital de São João (HSJ)… SONHO (Sistema de Gestão de Doentes Hospitalares) [1] [3] [7] [3]
Virtual Electronic Patient Record (VEPR) • Integration in one interface of several DIS • Clinical information of the patient in one single folder [8] ICU (Informação Clínica do Utente) • VEPR • Integration of the various DIS with SONHO • Collection of the information for a central base in report form • Available for reading by medical doctors through the intranet of HSJ [3] [9]
ICU… • It’s available to the users for about one year • Since then its use has been increasing [3] Objective • To evaluate the reasons for use or non-use of HSJ’s ICU system by medical doctors at HSJ
References 1. Aula sobre Registos Clínicos Electrónicos do Curso de Informática Médica que se encontra em http://im.med.up.pt. 2. Richard S. Dick, Elaine B. Steen, and Don E. Detmer, The Computer-based patient record: An Essential Technology for Health Care, National Academy Press, 1997. 3. R. Cruz-Correia, P. Vieira-Marques, P. Costa, A. Ferreira, E. Oliveira-Palhares, F. Araújo and A. Costa-Pereira, Integration oh hospital data using agent Technologies- A case study (2005). 4. Torchio M, Molino F, Sestero D, Seidemari C, Molino G. Na electronic madical diary for computer assisted patient management. Minerva Med.2003 Jun; 94 (3): 167-79. 5. Coiera E. Guide to medical informatics, the internet and telemedicine. Arnold Publishers, London, 1997. 6. Uckert F. et al. Functions of an electronic health record. INT J Comput Dent. 2002 Apr-Jul; 5 (2-3): 125-32. 7. Lenz R and Kuhn KA. Integration of heterogeneous and autonomous systems in hospital. Business Briefing: Data management & Storage Technology, 2002. 8. Manual do utilizador do ICU 9. Panfleto de divulgação do ICU
Type of the study: Transversal and observational study • Target population: about 1000 medical doctors working at HSJ • Sampling method: simple random sampling • Sample: 100 medical doctors • Pilot questionnaire: applied to 4 medical doctors of HSJ selected at random • Questionnaire – personal structured interview: • Evaluate the use, frequency of use, opinions and influence of some variables (sex, age, medical specialty) • Introduction of the data in SPSS
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