Systems of this class are designed to provide information support for the adoption of both specific medical decisions and the organization of work, control and management of the activities of the entire medical institution. These systems, as a rule, require the presence of a local computer network in a medical institution and are information providers for medical information systems of the territorial level.
Information systems of consultative and diagnostic centers designed to organize consultative and diagnostic examinations of patients, registration, processing, analysis, accumulation and storage of diagnostic information.
Information systems of polyclinic institutions are designed to organize and analyze the work of specialists and medical and diagnostic rooms of a polyclinic, store information about the population attached to this polyclinic and form this necessary medical and statistical reporting.
Information systems of medical institutions of stationary type are intended for registration of patients' appeals to the admission department of the hospital, their movement through the medical departments, accumulation in the database of anamnestic, clinical, diagnostic and other information, personalized accounting of medicines and the results of the patient's stay in the hospital.
Polyclinic and inpatient information systems generate invoices - registers for the rendered outpatient and inpatient care, presented for payment to insurance medical organizations.
Information systems of the territorial level.
These software systems provide management of specialized and profile medical services, polyclinic (including clinical examination), inpatient and emergency medical care to the population at the territory level (city, region, republic).
At this level, medical information systems are represented by the following main groups:
Information systems of the territorial health department, carrying out the accumulation and processing of information about the work of all medical institutions of the territory.
Personalized registers(databases and data banks) containing information about certain groups of patients (occupational diseases, diabetes, narcology, etc.).
Information systems of departments (centers) for the provision of emergency advisory assistance providing inter-hospital interaction for remote consultations, departure of specialists and evacuation of patients in order to provide highly qualified and specialized medical care.
Information systems of the Mandatory Health Insurance Funds, providing information support for planning and monitoring the financing of medical institutions through the CHI system.
Information systems for the organization and control of drug provision of the population, including accounting for subsidized medicines.
Medical information systems of the federal level
Systems of this class are intended for information support of the state level of the health care system of Russia based on data received from the territorial health departments according to approved statistical reporting forms.
Functional classification of MIS
Information systems (IS) at the level of medical institutions are primarily designed to provide information support for the main business processes of these institutions and, as a result, organize their work at a higher quality level.
These include:
Medico-technological IS;
Information and reference systems;
Statistical IS;
Research IS;
Educational ICs.
These ICs are used in medical institutions of various levels (from a general practitioner's office to large interregional and federal medical centers), in sanatoriums, diagnostic centers, blood transfusion stations, specialized centers (AIDS, family planning, etc.). Of greatest interest among them are medical information systems (MIS), integrating all of the above listed types of IS, which in this case act as subsystems of the general MIS.
The American Institute of Medical Records distinguishes 5 different levels of medical information systems:
The first level of MIS is automated medical records. This level is characterized by the fact that only about 50% of information about the patient is entered into the information system and in various forms is issued to its users in the form of reports. On given level typically covered are patient registration, discharges, in-hospital transfers, diagnostic entry, appointments, and operations. Information processes here go in parallel with the "paper" document flow and serve, first of all, for the formation of various types of reporting.
The second level of MIS is the Computerized Medical Record System. At this level, medical documents that were not previously entered into electronic memory (first of all, this is information from diagnostic devices obtained in the form of various printouts, scanograms, topograms, etc.), are indexed, scanned and stored in electronic storage systems (usually on magneto-optical storage devices).
The third level of MIS is the use of electronic medical records (Electronic Medical Records). At this level, an appropriate infrastructure should be developed for entering, processing and storing information from their workplaces. Users are identified by the system, they are given access rights corresponding to their status. The structure of electronic medical records is determined by the possibilities of their software processing. At this level of HIS development, an electronic medical record plays an active role in the decision-making process and integration with expert systems, for example, when making a diagnosis, choosing medicines, taking into account the patient's current somatic and allergic status, etc.
At the fourth level of HIS, which is called Electronic Patient Record Systems or Computer-based Patient Record Systems, patient records have many more sources of information. They contain all relevant medical information about a particular patient, the sources of which can be either one or several medical institutions. This level of development requires a nationwide or international patient identification system, a unified system of terminology, information structures, coding, etc.
The fifth level of MIS is called electronic record about health (Electronic Health Records). It differs from the system of electronic records about the patient in the existence of practically unlimited sources of information about the health of the patient, which allows you to accumulate information about his behavioral and social activities (smoking, sports, dieting, etc.). In fact, the MIS of the fifth level accumulates electronic health passports (Long Life Personal Health Record) of the population.
According to the current standard, medical information systems must ensure the implementation of the following functions:
Maintaining medical records (“electronic medical records”);
Formation of structural and economic descriptions (passports) of health facilities and their transfer to consolidated Database passports of healthcare facilities, which are maintained in the territorial funds of compulsory medical insurance and territorial health departments;
Registration of patients and maintenance of the register of performed medical services according to compulsory medical insurance;
Planning and recording of completed vaccinations;
Mutual settlements with HMOs and territorial CHI funds for treated patients;
Maintenance of regulatory and reference information;
Operational planning and accounting of medical care resources (beds, medical personnel, complex medical equipment, reception rooms, stocks of pharmaceutical products);
Planning and accounting for medical and diagnostic appointments, as well as referrals to other health facilities;
Submission of state medical statistical reporting to the territorial health departments;
Maintaining a database of registered diagnoses for the formation of disease statistics;
Formation of information about the availability of drugs available to patients, and keeping records of drugs provided to patients on benefits.
MIS should be a tool that ensures and organizes the work of a medical institution. To do this, it should cover the entire set of information about the medical services provided in it and should provide an opportunity to obtain various indicators of the activities of a medical institution, in particular:
Indicators characterizing the processes of providing medical care: timely detection of pathology, reasonableness of hospitalization, timely taking of patients for dispensary registration, analysis of discrepancies in diagnoses, the volume of diagnostic and laboratory studies; compliance with standards for the duration of treatment, deviation from the drug formulary in drug therapy; the share of paraclinical methods of treatment, that is, the compliance of the assistance provided with the standards and treatment protocols.
Outcome indicators (final results): reduction of labor losses and cases of disability; reduction in the duration of treatment, the level of hospitalization, the appeal to the SMP; reduction in mortality rates in working age; decrease in the level of morbidity and pain as a result of timely and effective medical examination and a high level of immunization; reduction in the number of “neglected” cases of oncopathology, tuberculosis, etc.
Treatment effectiveness indicators: absence of relapses, complications, cases of re-hospitalization; compliance of the level of costs with the volume of assistance provided; satisfaction of insured patients with the level of care provided; improvement of public health indicators, etc.
It should be noted that in addition to medical IS, specialized IS can be used in medical institutions, for example, IS of the accounting department, personnel department, group (department) for the repair and maintenance of medical equipment, etc., as well as specialized image storage systems, specialized diagnostic systems, etc. d. The modern concept of building medical information systems assumes their close interaction based on standard data exchange protocols such as XML, HL7, DICOM, etc.
At the same time, the information interaction of the MIS with the information systems of other medical organizations should be organized, in particular:
with other health care facilities and sanatorium-resort institutions;
with territorial health departments and medical departments of ministries and departments;
insurance medical organizations and territorial funds of compulsory medical insurance;
bodies of the State Sanitary and Epidemiological Surveillance;
medical schools.
This exchange is carried out in accordance with the standards (protocols) of information exchange, known to all participants in such an exchange. The protocols for information exchange in the healthcare system and CHI of the Krasnoyarsk Territory are approved by the Conciliation Commission and are part of the Tariff Agreement in the system of compulsory medical insurance in the Krasnoyarsk Territory. At the federal level, information exchange standards are developed and approved by the Ministry of Health and Social Development of the Russian Federation.
An electronic medical record (EMR, Electronic Medical Record, EMR) is an electronic collection of information related to the health of a subject (patient) that is created, stored, maintained and used by certified medical specialists and personnel in one healthcare organization.
Rationale for the need to use EHR in the treatment and diagnostic process:
1. Over the past 40-50 years, the amount of information a doctor operates with has increased several times and continues to grow. On the other hand, the technology of working with increased data flows has remained at the level of the middle of the last century. Accordingly, we need an effective "tool" for processing the ever-growing volume of medical information and a powerful "amplifier" of the doctor's capabilities.
2. With the exception of automation tools for accounting and personnel, most of the information systems implemented in healthcare facilities are separate programs or their complexes for solving specific specialized tasks. For example, registration of services and data exchange with insurance companies and compulsory medical insurance funds, registration of mortality, registration of the birth rate, registration of the incidence of diabetes, tuberculosis, etc.
3. For each "accounting", as a rule, a separate special software is supplied, which does not or almost does not interact with other programs. The more you need to "take into account", the more diverse programs are being implemented in each health facility and each new program requires to enter into "its" database all or part of the information that has already been entered into the database of another program, unnecessarily increasing the burden on staff.
4. The doctor, in addition to maintaining a medical record in paper form, is required to fill out statistical coupons, forms for registering patients with newly diagnosed diseases, etc.
The introduction of EMR removes the need to support the "zoo" of accounting programs and the formation of numerous accounting forms, because any report or accounting form can be received from EKM automatically at any time.
The use of modern computer technologies and the introduction of an Electronic Medical Record in healthcare facilities is the most effective mechanism that provides the ability to quickly structure, detail, analyze and use all the information recorded in the medical record.
Independent work "Work in MIS Bars"
Access via Mozilla Firefox browser
http://31.13.128.106/med2/
LOGIN: demouser
PASSWORD: demo2010
Cabinet: advisory cabinet
Exercise 1. Get acquainted with all the possibilities of MIS Bars. Mark what functions this MIS performs, and, using table "Functions of medical information systems", make a conclusion to which class of MIS it belongs. Directions: Make your notes with a plus sign (+). Your conclusion must be written after the table.
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Functions of information systems |
IP classes |
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Information support for the processes of diagnosis, treatment and rehabilitation of patients | ||
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Information support for the activities of doctors (pharmacological databases, guidelines for the use of medicines, patient management protocols) | ||
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Personal records of patients, maintenance and processing of medical documents | ||
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Accounting for medical care and medical services provided to patients, determining the need for basic types of medical care; assessment, control and quality assurance of medical care | ||
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Calculation of standards and tariffs for payment for medical care provided; organization of mutual settlements between healthcare institutions | ||
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Accounting, planning of financial and material resources and management of health care institutions | ||
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Monitoring the state of the medical, demographic and epidemiological situation | ||
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Collection and processing of medical statistical data, monitoring of the health status of the population, preparation and submission of state medical statistical reporting, analysis of statistical data | ||
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Decision support, including based on modern knowledge bases, inference methods, expert systems, etc. | ||
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Information exchange between healthcare IS, as well as IS of other departments (social protection, education, etc.) in standard exchange formats | ||
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Support for telemedicine technologies (telemonitoring, telemedicine consultations and consultations, videoconferencing, access to remote information resources) | ||
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Access to Internet resources; formation and support of own information Internet resources. | ||
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Support for the processes of education, training and retraining of specialists | ||
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Maintaining a database of regulatory and reference documentation | ||
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Automation of document flow in an institution |
Conclusion: __________________________________________________________________
Task 2. Get to know the IS menu. Answer the questions (the answer will look like this: Accounting/account registries)
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In which section, in which menu item can a new patient be registered? | |
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In which section, in which menu item can you sign up a patient for an appointment with a doctor? | |
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In which section, in which menu item can you see the schedule of doctors? | |
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In which section, in which menu item can you select and view a list of outpatient cards for a certain period of time (for example, the last month)? | |
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In which section, in which menu item, you can see the statistics by departments (number of beds in the department, number of patients in the department, etc.)? | |
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In which section, in which menu item can a patient be issued a sick leave? | |
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In which section, in which menu item can I add / change the structure of health facilities? |
Task 3. Indicate for which user (registrar, doctor, head of department, chief doctor, information system administrator) this or that section of the information system is intended and why.
Task 4.
Search the database of patients: find your namesakes, or surnames similar to yours, take a screenshot.
Task 5. Search for another patient (using an arbitrary surname, except for the surname Ivanov, the patient must be registered, otherwise it will not be possible to make an appointment). Sign him up for an appointment (payment - according to compulsory medical insurance). Take a screenshot.
Do not close the window that appears.
Task 6. Generate an itinerary ticket for this patient. To do this, press the button "Talon"
Task 7. In the workplace of the chief physician, find the patient you have previously recorded, take a screenshot.
Task 8. In the ACCOUNT point, view the journal of payments for the current month for cash. Take a screenshot.
Humanity, in the course of its existence, comes up with various opportunities to make life easier for itself and to simplify life. One of these tools, which frees from routine, is a medical information system (MIS), which helps to coordinate the work of the health care system.
Information system
What is generally understood by them? An information system is defined as an information processing system that works together with the people and financial resources on which the provision and distribution of information depends.
Automated system
An automated system is a complex that consists of automation tools for human labor and the personnel who serve it. The speaker performs the functions programmed in advance for it. If there are several automated systems (from two pieces), provided that the functioning of one directly depends on the other (others), then they are called integrated.
Medical Information Systems
Different definitions of MIS are given by the luminaries of science. But the most popular option sounds like this: a set of software, information, technical and organizational tools that aim to automate medical processes / organizations. But for completeness of information, you should read one more. It sounds like this: MIS is a form of organization of medical processes that enable medical personnel, if they have the necessary technical support, use a set of tools that provide the collection, processing, analysis, storage and output of medical information that relates to health and its condition for a particular person. In addition to conventional MIS, diagnostic and related IS are additionally distinguished. It was not possible to designate them in clear defined groups due to the fact that there is no clear state standard that would be qualitatively processed, therefore there is no generally accepted division into various medical information systems. Classification, however, is carried out by individuals or groups of specialists.
Classification of information medical systems
Due to the novelty of the technology, there are no state-approved standards yet, so I bring to your attention the following classification:
- Information services. Information service for patients. Aims to provide the widest coverage of operation and service maximum number people in the shortest amount of time.
- Information technology medical systems. The object of work is the patient, the user is a medical worker.
- Information-statistical medical systems. Generates the population of the served region. The division is carried out by objects and by the territorial principle.
- Research information medical systems. The main subjects of work are documents and objects of science. Additionally, they are divided into subsystems depending on the differences in the objects of description.
- Information-training and educational medical systems. Trainers provide support to those who go through the training and learning process. Educational systems are used to assess the level of knowledge.
But besides this, MIS are further divided into subsystems and have a number of additions. Thus, medical information systems, the classification and purpose of which is difficult, were moved to diagnostic and related types. Additionally, a determination is made as to whether the system is complex or not.
Complex systems
A medical information system (MIS) that deals with both administrative and clinical functions, and for which an electronic medical record is chosen as the core, is called an integrated automated medical information system. It includes:
- Caring for the automation of accounting, personnel and economic services, office work, engineering support, logistics - everything that allows you to automate administrative and economic activities.
- The system of personal accounting of medical care. Maintaining support for subsystems of procedural and diagnostic departments with a hospital pharmacy.
- Reference information. It can be as a complex description various problems, methods of their treatment, symptoms, as well as the schedule of doctors, laboratories, their level of employment and a brief dossier.
Diagnostic information medical systems
The task of this type is to receive, transmit and analyze data that have been obtained as a result of certain diagnostic or laboratory studies, using special external devices. Due to the frequency of cases when DIMS or MIS is installed and the difference in their functionality, they are considered as separate systems. But if there are medical information systems, then DIMS is considered to be its subsystem. Its purpose is to complement the main one.
Related information medical systems
Modules for the purpose of special use (usually medical or economic). SIMS can include personnel or accounting systems, full-fledged pharmacy systems (which can provide planning, procurement, and distribution of medicines and medical equipment), systems for automating processes in specific departments. Despite the inclusion of this topic in the article, in practice it is considered solely as an addition, the purpose of which is to increase the functionality.
Modern systems and their use
And finally, about some medical information systems in Russia, which are used (though not very common) in medical institutions.
A medical information system built on a modular basis. It is designed to automate the processes of hospitals and clinics. The number of modules for them is 11 for each institution. Allows data exchange and centralized collection of required indicators. Supports interaction between staff, collects data to inform the management of the institution in which LARS is installed. The medical information system allows you to work not only with staff, but also with patients and facilitate their interaction with a medical institution in matters of making an appointment, issuing prescriptions, sick leave, calling emergency care. Based on the received data, it can generate reports on the status of individual patients, doctors and medical institutions.
It is an integrated information and functional environment that has combined various classes of medical information systems (MIS). Support for hospital services - from financial reports and documentation to individual patient records. Important is the integration with and support of decision-making systems.
An information system of a medical institution that automates activities, planning and optimizes patient treatment processes. Allows you to reduce the time spent on documentation, coordinates the work of medical offices and laboratories, optimizes the use of labor resources, and organizes a rapid exchange of information.
The MEDWORK medical information system was developed by MASTER LAB to solve a set of medical and management tasks facing a modern clinic and hospital. Today, thanks to twenty years of experience in the operation and development of the system, we can offer a full-featured, scalable and open product - a working tool for the manager, doctor and all clinic staff. MIS Medwork complies with the requirements of GOST R 52636-2006 "Electronic medical history", follows the recommendations for ensuring functionality MIS MO of the Ministry of Health of the Russian Federation. As part of the open source software support, integration with and .
computer program MedWork © is designed to automate medical institutions of any profile and provides:
- Keeping a medical history and outpatient card
- Coverage of all main stages of the treatment process
- Obtaining and processing medical and financial statistics
- Preparation and printing of statements
- Planning appointments, medical work
- Formation of invoices for patients and accounting for services rendered
- Automation of the printing of certificates of incapacity for work
- Interaction with organizations and insurance companies on CHI and VHI
- Design and generation of output reporting forms
- Applicable in all types of medical institutions due to:
- Full user customization of all input and output forms
- Ease of administration and learning
- System scalability from use in a first-aid post to a large clinic, diagnostic center, multi-building hospital
- Flexibility and convenience of the system in setting up user profiles, in integration with existing programs, export-import of data from existing programs
- Openness of the system for refinement and maintenance both by the clinic staff and third-party developers
Disease history
In Medwork, the patient's case history is presented in the form of a patient's card, which is familiar to physicians, and consists of a set of documents (forms). Documents can contain data of various kinds: text, images, tables, charts, etc.
This allows you to store in electronic format any information about the patient and the course of treatment, including:
- survey results;
- descriptions of the functional state of the patient, diagnoses;
- information about operations, procedures;
- laboratory test data;
- treatment bills;
- images obtained from medical devices, a scanner or a digital camera.
Filling out the card is significantly accelerated through the use of formalized treatment regimens and replenishable and customizable reference books.
A user-friendly interface with the ability to group and sort documents allows the doctor to quickly find necessary information in the patient's chart.
Data from devices (ultrasound, cardiograms, analyzes, etc.) can be directly transferred to the patient's card using a special interface.
Extract from the medical history at the touch of a button
Data from the patient record can be presented in a freely defined form using a powerful and customizable statement mechanism. The creation of statements occurs automatically and frees users from the lengthy work of collecting information - a few seconds, and you get a ready-made statement in the form of a document Microsoft Word.
The most convenient work with disability certificates
Working with sick leave certificates of a new sample (approved by order No. 347n of 01/26/2011) in MedWork is as simple and intuitive as possible. The document "Sick leave sheet" is embedded in the patient's card, MedWork itself fills in most of the fields of the sheet with data from the database or templates. Verified data from MedWork is printed on the sick leave form. Data on all sick leaves issued are stored in MedWork.
Statistical reports for all areas of activity
Medwork allows you to get any statistical reports for any period: on medical work, statistics on admissions, incidence, various financial reports, etc. Creating a new report does not require additional programming and is done using a special wizard included with Medwork. open format data makes it possible to access the system from any known report generators.
Convenient appointment scheduling
Users can interactively create a variety of queues, lists of patients for referral to other workplaces. A simple and convenient interface for working with patient groups makes it possible to schedule appointments at any workplace, from a treatment room to planning and accounting for operating lists
Setting up and developing the system in the process of work by the specialists of the medical institution
Medwork is highly customizable and can work in any healthcare setting. Such concepts as departments, lists-queues, user groups make it possible to flexibly describe the structure of the clinic and the technology for passing the patient through various stages of the treatment process.
Editing and replenishing the library of introductory forms, statements and reports using a convenient and powerful editor, as well as changes in the structure of the database can be done in the process and does not require special skills. The open architecture of the system makes possible connection To her software modules, designed by users, allowing the system to expand functionally as the clinic expands or new treatment regimens are introduced.
MIS architecture
The MEDWORK medical information system is a comprehensive solution.
The key concept of the system is the profile. For example, the profile of the registry, the admissions department, the guard nurse, the procedural nurse, .... etc. In total, within the framework of the Standard Configuration (complete delivery of the system), more than 60 profiles have been developed for different types of medical institutions. All profiles are available for use. A set of profiles forms a Configuration. Examples of configurations - Typical (full), Hospital, Polyclinic, Private clinic, Dialysis, IVF clinic, etc. Clients can easily modify and develop profiles and configurations to suit their needs without loss of data integrity.
Selecting a MIS profile
Key functionality
"Electronic medical record"
An Electronic Health Record (EMR) is a convenient, automated outpatient patient record or (for hospitals) an electronic medical record. EHR complies with the requirements of the state standard "Electronic Medical History" (GOST R 52636-2006).
Installed on workplace medical specialists of various profiles: a doctor, a nurse, a laboratory assistant, managers of various levels of a medical institution, as well as wherever there is a need to enter information into a patient's card.
Short list of features:
- Provides users with the ability to quickly and conveniently enter patient information.
- Ensures the security of access to the EHR, taking into account the user's access rights to medical information approved by the medical institution.
- Allows you to view the patient's EMR and quickly find the information you need in large volumes of medical records.
- It makes it possible to generate various extracts, certificates, epicrises on the basis of the EHR, print them and store a copy of these documents.
- Provides the ability to visually view the medical data on the patient: diagnoses, appointment list, build various graphs, etc.
- Allows you to set up convenient protocols for doctors of any specialty.
- Allows you to attach various documents to the EHR, for example, voice messages.
- Allows you to electronically transfer to the patient his EHR on various media in a format that can be viewed on any computer.
- It is tightly integrated with almost all modules of the MEDWORK system: service accounting, pharmacy, bed capacity, image processing, and others.
Features and Benefits
Rapid completion of the outpatient card and medical history
Entering examinations, test results and other medical information is done by creating records of various profiles, specially designed for doctors of various specialties: general practitioners, ophthalmologists, surgeons, cardiologists, pulmonologists, etc.
The EHR/electronic medical record comes with ready-made entry forms, developed in collaboration with doctors and debugged over many years of using the system in medical institutions.
The system provides tools designed to speed up the typing of text information:
- Context directories are attached to input fields and contain frequently used terms and phrases. The hierarchical structure of directories allows you to automatically construct long phrases. The standard delivery of the EMC includes many ready-made reference books that can be expanded independently.
- Mode search allows you to quickly find the necessary terms in the reference book.
- Tool templates allows you to copy data from previous records of the medical history, and also facilitates the input of the same type of information (protocols of operations, medical examinations, etc.).
Entering heterogeneous information
MEDWORK's EHR/Electronic Health Record offers the clinician a powerful arsenal of data entry tools tailored to a variety of information types.
The program provides for the possibility of typed input, that is, filling in the fields of text, numeric, boolean types, lists and dates, which in turn provide additional features when collecting statistics and plotting graphs. The scheme editor allows you to make graphic marks and drawings, for example, on the image of the cornea of the eye. EHR can contain images in any of the most common formats.
Data entry tools are varied. They can be universal, highly specialized, with elementary or complex logic of behavior. The open architecture of the program allows you to constantly expand and improve the set of such objects.
Flexible configuration of the database structure and input interface
Data can be entered not only quickly, but also in full accordance with the professional needs of a specialist.
The standard set of screen forms included in the MEDWORK medical information system package can be easily modified and expanded through the use of built-in form editor. Using this handy tool, the user creates new forms and input fields, changes appearance desktop and the relative position of the main interface objects. Thus, it is possible at any time to reflect new types of studies in the system or optimize the maintenance of an electronic medical record without resorting to the help of developers.
Switching between data entry mode and input form editing mode is instantaneous, but can be disabled to protect against unskilled use.
It is also possible to change the structure of the database. You can add fields of different types to tables, storage formats change and
Convenient and fast search of information about the patient
The EHR/electronic medical history of the MEDWORK medical information system was designed in such a way that not only the input, but also the subsequent viewing and analysis of data were convenient, visual and informative, and any information stored in the MEDWORK database was easily accessible to the user.
An important tool for viewing a medical record is the object "extract", which reflects the main indicators of the patient's health status, the development of the disease, the prescribed courses of treatment and allows you to quickly go to any screen of the dossier.
An object "Appointment List" shows when and what medications were prescribed to the patient, for how long and which medications were canceled ahead of schedule.
Another interesting feature system is the ability to analyze using charts change of any numerical parameters in time.
ICD-10 Handbook
The EHR/Electronic Medical Record contains the 10th Revision International Classification of Diseases guide, which is used to enter diagnoses in a standardized manner.
It is possible to formulate your own diagnosis and link it to the "official" ICD diagnosis, as well as many other useful features.
For example, a doctor can find some diagnosis in the ICD according to keyword, MEDWORK will translate it into English using the English version of the ICD and will complete the request in the medical database MEDLINE on the Internet to search for articles on the subject.
VIDAL® Handbook
The prescription tool is implemented based on the interaction of the MEDWORK system and the built-in database of the VIDAL® electronic drug reference book
Formation of documents for printing
Creating Documents different type(reports, letters, extracts, conclusions) is the daily work of a doctor. The MEDWORK EHR/Electronic Health Record provides tools that greatly facilitate this process, as well as ensure that all records are securely archived electronically.
Each patient's record contains a set of documents sorted into categories and provided with special descriptors. The simplicity of classification allows doctors to quickly find the necessary documents in the archive.
Work with texts can be carried out either through built-in text editor , or using Microsoft Word ® .
Data can be copied from a patient record directly into a document.
Letters and other standard documents can be generated automatically based on pre-prepared templates. You can add fields from the electronic medical record to the templates, which are filled with real data during the letter generation process. Documents created from templates are automatically attached to the map and can be edited manually.
Additional automation options
Integration with laboratory and other systems
Integration with laboratory systems significantly increases the productivity of the laboratory and increases it throughput. The presence of a laboratory module in the system reduces the costs of a medical institution for automation, making it possible to use a single information system in both medical and diagnostic departments without the need to integrate heterogeneous software products.
The call center will automate the work of registries, receptions, doctors and other departments with incoming calls, as well as systematize the information received. Based on the indicators obtained as a result of the work of the Call Center, the CC administration will be able to:
- evaluate various aspects of their activities, for example, the effectiveness of advertising campaigns and the dynamics of demand for medical services provided,
- optimize the work of various departments,
- determine the profitability of existing areas,
- determine promising directions for further development of CC.
MIS can be integrated with other application systems, for example: accounting system, personnel, warehouse, etc.
Personal plastic cards
Personal plastic cards can be used in various processes, both by patients and employees. For example, universal plastic cards can be used to identify users in the System, preventing unauthorized access, identification of patients in the registry or the possibility of using a plastic card as an "electronic wallet".
Work at a distance with the schedule of the medical institution through the medihost.ru portal.
The ability to work remotely with the work schedule of doctors and offices through the www.medihost.ru portal allows you to:
- for an employee to work remotely with the System, including with the patient's electronic medical record or in the consultation mode;
- for the patient – to remotely make an appointment with a specialist, find out the results of their tests, etc.
Additional information services also improve the efficiency of the health facility network and patient satisfaction. These services include the following options:
Deployment information portal, allowing:
- Inform patients about news
- For patients to remotely receive the necessary information (for example, to find out the results of their tests)
- Allow patients to remotely interact with the health facility network (for example, make an appointment with a doctor or cancel an appointment, contact a receptionist using an instant messaging service)
2.1. BASIC TERMS AND DEFINITIONS
During the period of electronic presentation of information, computer systems become a tool of labor, for which information is the subject and result, and collective access to this information becomes the most common way of organizing production. Thus, the appointment computer systems is gradually shifting from the automation of manual labor of individual workers to the informatization of the activities of the entire staff. Information becomes the main corporate resource.
When it comes to medicine, ensuring timely access to information becomes critical when it comes to people's lives. Ownership the right information, relevant or historical, is often the only thing that a doctor lacks in order to provide the patient with the necessary medical care in a timely and qualified manner. Routine workflow, lost copies of documents, geographically dispersed information about the same patient, lack of qualified search methods - all this takes time and energy from medical specialists and significantly reduces their efficiency.
In addition, the amount of information that the doctor must constantly keep in mind in order to be able to assess the condition of each patient is certainly enormous. When the amount of processed information exceeds the value of some critical parameter, individual for each person, the ordering and systematization of this information becomes impossible. To save the ability handle continuously increasing volumes of data, a transition to a new way of collecting and processing information is necessary, which can be considered as some individual information revolution, the result of which should be the beginning of use in professional activity a specialist of a new tool - an information system.
Let's try to define what is meant by an information system. The official definition of the concept of "information system" is given in the "Federal Law on Information, Informatization and Information Protection" (N24-O3, adopted by the State Duma on January 25, 1995, signed by the President of the Russian Federation on February 20, 95): "An information system is an organizationally ordered set of documents (arrays of documents) and information technologies, including with the use of computer technology and communication tools that implement information processes.
For this tutorial, we will use the following definition: Information system - it is a set of methodological, software, technical, information and organizational tools that support the functioning of an informatized organization.
Depending on whether it functions independently (without human intervention) or not, the information system can be automatic or automated.
Automated information the system provides the ability to perform both manual and automated processes. The user (operator), which is a link in such a system, and computer facilities work together to process and further use information.
Since the diagnostic and treatment process cannot proceed without the participation of a person (physician), in the future we will have in mind only automated systems.
Introduction into medical practice and development of computer hardware software we will call automation of the treatment and diagnostic process.
From here we can give the following definition of a medical information system: “ Medical Information System (MIS) is a set of software and hardware tools, databases and knowledge designed to automate the processes occurring in a medical institution.
Open medical information systems. The definition of “open” HIS means that they implement procedures for the exchange of medical and economic documents with other systems that meet generally accepted rules and standards. To implement the openness of medical information systems, it is necessary to first develop rules and standards for their interaction. Ideally, two open health information systems can interact without any additional effort on the part of their developers.
We emphasize that openness systems in this case does not mean the general availability of the information stored in them. The owners of each system decide for themselves what information can and cannot be transferred to other institutions.
2.2. MAIN OBJECTIVES OF IIA CREATION
The main goal of healthcare informatization as a whole can be formulated as follows (Health informatization concept): the creation of new information technologies at all levels of healthcare management and new medical computer technologies that improve the quality of medical and preventive care and contribute to the implementation of the main function of protecting public health - increasing the duration of active life.
In addition to the designated main goal, the IIA faces a number of interrelated and very important tasks, among which the following can be noted:
Creation of a single information space to speed up access to information and improve the quality of medical records;
Monitoring and managing the quality of medical care in order to reduce the likelihood of medical errors and eliminate redundancy in prescriptions;
Increasing the transparency of the activities of a medical institution and the effectiveness of management decisions;
Analysis of the economic aspects of the provision of medical care is a very important task for domestic healthcare, which is moving to a commercial basis;
Reducing the time of examination and treatment.
2.3. FUNCTIONAL CAPABILITIES OF MIS
The main features of MIS include:
Collection, registration, structuring and documentation of data;
Ensuring the exchange of information and the creation of an information space;
Storage and retrieval of information;
Statistical data analysis;
Monitoring the efficiency and quality of medical care;
Decision support;
Analysis and control of the work of the institution, management of the resources of the institution;
Support for the economic component of the treatment process;
Training.
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