Author(s): Carlos Blazquez-Dominguez , Roberto Castaneda-Sheissa , Luis Hernandez-Martinez , Raul Martinez-Campo and Hector Vazquez-Leal
Aug. 15, 2011
ABSTRACT:
The health system for any country is one of the top priorities to guarantee the proper development for their citizens. For the specific case of Mexico, management of medical records is still being done using physical files whether patient attends a public or private physician or hospital. This poses a potential problem for the health structure and the patient because physical files tend to deteriorate, damage, could be stolen or mishandled. One possibility is to evolve from the use of physical files and create electronic medical records. Mexico already has an official standard for medical records; this standard could serve as the foundation to devise an electronic universal record. The idea for the electronic universal record is to serve as the base to implement an electronic public health scheme. This article will provide several key aspects to take into account in order to provide an efficient, secure and cost efficient electronic medical record. Aspects to be considered include: standardized medical nomenclature, clinical procedures, data transmission standards, legal aspects, electronic security, and data storage schemes. The impact of this proposal for Mexico will be discussed in detail.
The information and communication technologies (ICT) have impacted in all areas of society, penetrating the culture is such a way that youth have turned much of their social and leisure activities to the electronic media. Nevertheless, ICT's have also caused notorious impact in the productive and educational sectors. In the health area, the use of information technology and other sciences is known as medical informatics or medical computing; it exists since the origins of computers in the 50's. Health informatics includes computers, clinical guidelines, formal medical terminology, information and communication systems, and medical information standards among other aspects [1-7]. Electronic medical record is a key aspect for medical informatics, because around it there are areas like: consulting room [8,9,10], nursery [11,12,13,14,15], mental health [16,17], intensive care [18], clinical laboratory, clinical imaging [19,20,21], cardiology, blood bank, among others. However, in the United States only 5% [2] of providers of general medical services (family doctors) use electronic systems for medical records and just 19% of hospitals have integrated systems of medical software [3]. This fact is alarming if, only in that country, 98 million people annually dies due by direct medical malpractice [2]. Mexico does not escape of such problems; even the government agency named National Commission for Medical Arbitration (CONAMED [22]) was created to resolve controversies caused by medical malpractices. Nevertheless, this action is corrective, while preventive action would be the developing of an integral software platform to improve the medical services in general. Besides, it has been estimated that United States could save 77.8 billion dollars [2] if an integral, and universal, software system is deployed [23], allowing to infer, even with the economy scale, that implementing a Mexican integral health electronic system would help to achieve big savings, derived of the bureaucracy decrease, optimization of resources, disease prevention, standardization, among most important. Penetration of medicalinformatics in health sector has been so gradual that despite humankind has been able to take men to the moon 4 decades ago; still is not possible for most developed countries, that a general doctor access an electronic medical record "comprehensible" for his patients from anywhere, because there is not even a standard version or "universal" of such file.
Nowadays, the market for hospital and clinic management systems is segmented in medium and small companies, that on one side, develop particular solutions for specific areas in health services, leaving in the background aspects like interconnectivity between different areas and, on the other hand, do not comply with standards that allows import and export results between programs created by different companies. Thus, the health system works as a granulated entity, such that even within the hospital, data exchange between different departments is made through paper, although electronic and informatics systems are deployed in the respective departments.
Electronic Medical Record
In Mexico there is an official standard related to the medical record (NOM-168-SSA1-1998), which was issued in 1998 and subsequently amended in 2003 to include and validate the potential for an electronic medical record. Hence, this standard for the Mexican medical record, should serve as base for the creation of a standard electronic file for all the country. Besides, such standard is complemented with other standards like:
NOM-003-SSA2-1993.Provision for human blood and its components with therapeutic purposes. NOM-005-SSA2-1993.Provisions for family planning. NOM-006-SSA2-1993.Prevention and control of tuberculosis as primary attention to health. NOM-007-SSA2-1993.Attention to women during pregnancy, birth and puerperium, and newborn. NOM-008-SSA2-1993.Nutrition control, growth and development for kids and adolescents. NOM-013-SSA2-1994.Prevent and check oral diseases. NOM-014-SSA2-1994.Prevention, treatment, and control womb and mammary cancer in primary attention. NOM-015-SSA2-1994.Prevention, treatment, and control of diabetes Mellitus as primary attention. NOM-017-SSA2-1994.Epidemiological surveillance. NOM-024-SSA2-1994.Prevent and control acute respiratory infections. NOM-025-SSA2-1994.Provision of health services in integral attention units for Medical-Psychiatric Hospitals.
These standards support the standard for the medical record, so they have to be included in the design of the electronic version of the medical record. Currently there is not a standard way to design an electronic medical record [24, 25, 26]; inMexico the starting point is the official standard for the medical record. Nevertheless, the standard just dictates the information to request, but not the way to organize it electronically, and in this aspect, organization, there is still more work and research to perform. There are several aspects to consider when the electronic medical record is implemented, like:
Access speed and storage capacity. When it comes to health, access speed to clinical information of a patient could, literally, save his life [20]. The volume of medical information produced by a registry of patients of about 500 thousand people may be in the order of 1.8 terabytes monthly [27], so search for information fast is a complex task. At present, there is a system with 8 millions of patients which performs 300 thousand queries in day at a cost of 200 million dollars [3]. Figures mentioned before should be escalated if the population of Mexico is considered since it is over 100 million inhabitants, this is when can be inferred that data base technologies commercially employed nowadays could not be able to handle efficiently such information load. Nevertheless, there is a data base named Big Table [28], which is a high performance data base, designed in a structured way under a distributed storage data scheme, capable to store data in the order of petabytes based on a distributed network with thousand of servers; such data base represents, philosophically, the way to follow in order to store such amount of information that an electronic universal medical record could generate, taking into account the huge number of health professionals (medics, chemistries, radiologists, nurses, social services, administrative, among others) that would access the system for various purposes. Robust. The system must be functional no matter what happens, 24 hours a day, all year long. Besides, must be guaranteed the integrity of the information when the system fails or sabotage attempts. This implies the use of data redundancy schemes and servers that allows keeping the responsiveness and the reliability even under extreme load conditions. Flexible. There are no patients alike; each person is an individual with his own life story and, therefore, diseases. So, the electronic medical record should be adapted to the particularities of each patient. Following, a scheme of information hierarchy is proposed and extended [4]: Information unit. The medical record is divided in sub-blocks of information until the minimum expression is achieved, keeping the "meaning" within the health context of the patient, it is named information unit. For example, the glucose level in blood is an information unit, which has properties as values and units. Each information unit must have an identification code. The origin of an information unit could be by capture (manual) or directly of electronic equipment (automated). Class. It is the group of information units that recreate a particular aspect of the health for an individual. Could be a disease, laboratory study, clinical history, among others. For example, a complete blood test is made of glucose, urea, creatinine, cholesterol, and uric acid, which are considered as information units. Object. It is a specific case (in terms of time) for one or more classes. For example, blood test class is one that turns into an object when is the blood test for a patient, performed at a specific date and time. Section. A section groups in logical way different objects. For example, surgical procedures could be a section that includes the following objects: acute appendicitis, caesarean, etc. An important aspect of a section is that, while maintains logic, may include objects from different sections. For example, a laboratory test could be in the section "surgical procedures" and the section "clinical analyses". E-Views. The way that information is displayed to the user (units, objects or sections) using Web technologies; this content should be dynamic in order to adapt to user needs, which is the one that interprets the data. There should always be possible to create different views for new users or when scientific advances are achieved. E-Forms. It is the user interface where information for units or objects is captured. A form based in Web technologies [29, 30, 31] would be a viable option, because the experience of the people using the Internet would be taken into account to use in a more efficient way the electronic medical record and, simultaneously, opens to adopt a scheme of hospital management and public health on line. Secure. The information of every patient must be protected with different security schemes like passwords, electronic health cards and digital signatures. The desirable characteristics mentioned above about the electronic medical record (EMR), provides a glimpse of the complex correlation and dependence between several hospital areas when the medical record is filled for each individual or patient.
Official standards establish that all medical records must include: clinical history, medical notes in case of emergency, medical notes in case of hospitalization, notes after surgery, improvement notes, nursery notes, notes for auxiliary services of diagnose and treatment, letters of knowledge about information, voluntary discharge notes, notification notes for public prosecutor, and notes in case of death or foetal death. This standard details all the required information whether it is medical as for identification (including name of patient, date, place name of the doctor or assistant that created the note) that the note must include. Therefore, this information can be subdivided, classified and stored according to the already mentioned criteria.
Electronic medical record for the newborn
The electronic medical record is a tool that allows doctors to visualize health of their patients in an integral way both in content and in time. Truth is that health problems, in particular the chronic, have usually an indelible mark evidenced when the medical record of the patient is observed through long time.
The standard ( NOM-007-SSA2-1993) for Attending Women during Pregnancy, Birth and Puerperium, and Newborn at section "5.11 Registry and information" details all the information that about the mother and newborn should be gathered for statistical reasons, touching aspects like: vaccination, maternal death, fetal death, gestational age births, abortions, among other aspects, birth or death certificate. Pregnancy, because of its importance and complexity, must be filed in a section of the electronic medical record for women. Considering all the critical aspects of monitoring pregnancy helps to decrease maternal deaths. In this sense, standard NOM-007-SSA2-1993 provides enough information to create a robust section about pregnancy and birth that allows the doctors, for instance, use the electronic medical record as the base to plan the labor and delivery surgeries.
While conducting statistics related to birth and newborn is important for health state policies, it is also equally important to establish what information should be stored in the medical record for the newborn, situation missed in such standard. This would have direct impact in the health of the infants, since many deaths happened during the first year of life would be preventable if information about the newborn is standardized and regulated. In this context this question should be asked: what medical information from the medical record should be transferred from the mother to the newborn? How much of the privacy of the medical record of the mother should be "invaded" in order to provide the newborn with more informed treatments and, therefore, more reliable? The mother "should," decide which information should or should not be transferred to the baby's medical record? Health and legal implications are broad [45, 46], so this process should be regulated by official standards. It is considered that all health data of a mother involving the evolution of pregnancy and birth of the product, are important aspects that cannot be left in limbo of ignorance, to baby's benefit. Although Human Rights indicate that privacy of the mother's EMR is violated [45, 46], this has to be transferred to the baby's EMR, especially everything that relates to the evolution and good health for the newborn and leave out unrelated clinical aspects. Setting aside the legal aspect, it is known that the relationship between baby and mother is so tight that the newborn health is intimately related to the health of the mother previous to the delivery and after it (when the newborn consume breast milk). Information proposed to extract from the mother's medical record is [4]: Mother's age, date of birth, maturity, mode of delivery, duration of membrane rupture, birth weight, diagnose and related procedures, among others.
Benefits And Innovation Opportunities
Create a Mexican electronic file, under the framework of standards like: medical nomenclature, data transmission, image handling; would allow opening a new frontier in the health system to directly benefit patients.
Medical informatics has proven to be a fundamental tool in the process of modernization of the public health system. The openness of the society to such information systems, in particular the universal electronic medical record, is a slow process but one cannot be stopped, because the benefits to implement such modernization far outweigh the debatable aspects both moral and legal. The advent of a universal electronic medical record accessible from the internet would allow an immediate improvement on the medical attention increasing the quality, and avoid adverse events by having the background of the patient; thus the incidence of lawsuits against the medical staff, service provider be kept to a minimum, also being source of useful information to researches in the health field. The economical and cultural dynamics of countries like Mexico delay medical informatics applied to public health systems, making it scarce or almost null. This situation, curiously, can be seen as an advantage, considering that advanced countries like United States or England started the use of medical informatics applied to the health system even before the appearance of the internet and other advanced technologies, so to migrate their infrastructure to new technologies represents an astronomical cost even for their strong economies. Nevertheless, Mexico, practically, is virgin territory to implement an electronic health scheme nationwide, so it is urgent for the government, researchers, and general public to sit down to discuss and define the future of our public health system in the regard of medical informatics, at the present time, that high investment costs in the health sector overwhelm the national budget. Prevention is an alternative to reduce costs and, in this area, to have a "generational" electronic file would greatly help to incise on the patients and their actual health condition.
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Full Text:
Newer healthcare technologies and treatment procedures are being developed rapidly, and clinicians are incorporating them into their daily practice. They are integrating the past and the present knowledge for better patient healthcare. Previously, it had been difficult to organize, store and retrieve medical and patient information. But, today, with the advent of computers and, moreover, information technology has led to the development of medical informatics that is helping physicians to overcome these challenges. Medical informatics deals with all aspects of understanding and promoting the effective organization analysis, management and use of information in healthcare, which are being highlighted in this review paper.
The computer revolution has unfolded in the past 50 years and, after four generations of computer hardware, computers in medical systems show widespread use. The computer is now a well-established tool in medicine and is employed for a variety of functions ranging from clerical tasks to complex clinical simulations. The medical research depends heavily on computers. They have influenced our habits and attitudes and the way we work. Computers have not only influenced individuals but have also have changed institutions. Companies now have on-line workers, digital libraries and dial-up researchers, [sup][1] with the ability to perform data acquisition, signal processing, storage and analysis, pattern recognition, data reduction and transformation, real-time interpretive calculations, manipulations and detection of detrimental changes in physiological functions for production of appropriate warnings that distinguish it from simple data capture to computerized monitoring systems. They also provide data retention for long time periods along with graphics data displays. The development of computerized monitoring systems requires considerable skills in engineering and programming so as to make the mode of operation much simpler, with fewer complications, thereby aiding the physicians and healthcare professional in patient healthcare monitoring and care. [sup][2]
The internet nowadays is a very useful tool in healthcare and plays a significant role in the advancement of biomedical instrumentation. For example, online searches of books and journals for latest medical research and clinical information from medical libraries can be easily made available through CARL and MEDLINE. This shared information through computers is creating a knowledge explosion around the world. Many hospitals are transferring their medical records (worldwide) via the internet. But, many do it through intranet using WAN or LAN due to security reasons. [sup][2] The huge impact of internet has led to the development of internet telephone, which might be used to conduct voice conversations through the internet computer data link. This will allow higher signal quality without broken speech and enhance biomedical communication using voice, data and pictures. Many online consumer health information sites are available providing discussions on various subjects of the mind and body. These are helping in creating awareness about health-related issues to the society at large. [sup][1],[2]
The computers are involved in improving the quality of patient care and reducing the costs, thereby enhancing self-management of chronic diseases. Few such examples of clinical/hospital information systems are Computer Stored Ambulatory Record (COSTAR), Regenstrief Medical record system (RMRS), Health Evaluation through Logical Processing (HELP) etc., which have been widely accepted and employed worldwide for better patient care monitoring. [sup][3] This has led to an emergent need for having a better and faster healthcare/clinical information system to meet the day to day needs of the growing ailing population, thereby aiding the physician in providing treatment to the ever-growing demand for healthcare facilities and the threat of emerging diseases arising every now and then.
Health Information System
A health information system is a system to facilitate the collection, processing, analysis and transmission of health information, which can help in organizing and operating health services and also can be made useful for research and training of health service personnel. The uses of the health information system are:
*To ascertain the health status of the population, that can help in quantifying their health problems. *To ascertain the local, national and international health status. *To ascertain the effectiveness of the health service. *To ascertain the degree of satisfaction of the beneficiaries from the health service. *To initiate research incase of the outbreak of new disease or health problem. The different sources of health information are:
*Census. *Registration of death and birth. *Hospital records. *Sample registration system. *Morbidity registers. *Health manpower statistics. [sup][4] Growth of Medical Informatics
Medical informatics or, rather, information technology (IT) in healthcare, has globally revolutionized the growth of the healthcare industry. With the sole intention of implementing "paperless" working, along with optimal outcome and improved efficiency, the solutions provided by IT companies to the healthcare industry are immense and innovative. Many globally renowned organizations like G.E., Infosys, Tata Consultancy Services, Sobha Rennaisance Information Technology Pvt. Ltd. (S.R.I.T), etc. are working in this area. They provide many hospital and patient-centric solutions. The solutions include Hospital Information Management System (HIMS or HIS) with various modules and subsets aiding from patient entry till his discharge from the hospital. These include Electronic Medical record (EMR or CPR), laboratory, radiology, dietary, housekeeping, wards management, insurance and contracts management, administrative, inventory and financial management, patient relationship, clinical knowledge management, medical decision making (Expert systems), communication systems (PACS), etc. [sup][5] All these play a vital role in hospital administration, better healthcare practices and in the day to day functioning (operations) of a hospital system.
The different solutions being offered by these organizations as apart of HIS include:
Hospital Information Management System
Hospital Information Management System (HIMS) is dedicated to managing the automation needs of virtually every segment of the healthcare environment. It computerizes operations pertaining to administrative, financial, clinical, specialty and support and maintenance business workflows. It supports various front office operations like wards, ICUs, OTs, laboratories, radiology, pharmacy, blood bank, medical records and billing. These are integrated with back office modules like materials management, financial management, engineering, housekeeping, food and dietary services, HRMS, payroll, hospital waste management, occupational health, illness and injury. It provides a total integrated solution for the hospitals to meet their day-to-day requirements. [sup][6]
It is one of the healthcare modules provided to the clientele as an end-to-end solution for their healthcare needs. It is widely used by the hospitals for better and improved patient care. This module is being widely accepted and employed by different hospitals worldwide for providing the benefit of better healthcare and patient monitoring. This module has several core modules comprising of different subfunctional modules that help consolidate patient's clinical information and also help assimilate financial and administrative information across the healthcare enterprise. It is a patient-centric solution, capable of coordinating the delivery of multiple healthcare services like revenue enhancement, cost containment and excellent patient care, assisting healthcare institutions to rapidly move their enterprise toward a better healthcare environment based on international standards. [sup][6]
Patient Registration Module
It is complimentary to most HIMS and provides staff and employees with easy and convenient access to information for better patient service and care, as per his preferences and permissions. It also helps hospitals manage workflow and patient flow using patient module features. [sup][7]
Radiological Information System
It addresses the requirements of radiological investigations. It provides information about the different radiographic diagnosis conducted in a given time frame. It manages the information into an easy-to-use format, integrating healthcare enterprise, delivering optimal operational efficiency, lowering costs and offering better patient care. The system may be integrated with a telemedicine system for electronic transmission of radiological images from one place to another for purposes of interpretation and/or consultation.
It is a comprehensive end-to-end solution for dental hospitals and dental clinics. It provides dental surgeons to have online information regarding the latest tools and techniques in dentistry providing better knowledge to the physicians and thereby improved healthcare facilities to patients.
It is a high-end viewer with superlative features, designed to enhance and optimize radiologist workflow and is a hardware-accelerated multimodality diagnostic workstation, which facilitates faster and efficient image processing and manipulation techniques. It also analyzes, displays, stores and retrieves images from PACS and other modalities. The workstation communication is based on the DICOM 3.0 standard, which enables communication with any DICOM-compatible product, like scanners and workstations. [sup][7] It is employed in different imaging modalities like CAT scan, MRI, PET, SPECT, digital X-ray machines, etc. for better image processing and visualization.
The use of modern IT structures in medical practices and the hospital contribute much to the optimization of the processes involved in patient care and administration. The basic aim of these systems is to support the extremely complex reorganization of clinical and administrative processes and to improve cost management. Hospital management is being faced with dynamically varying conditions that require quick reflexes (responses). The need is for lower treatment costs and real-time processing along with handling emergency situations like doctor's strikes, which is so common in many countries nowadays, alongside handling huge patient inflow. The advent of management information systems (MIS) is enabling hospitals to react dynamically to such events and adapting to changes much better. [sup][8]
The major factor leading to the development of these systems was cost issues involved in hospital medical and patient care duties and determining the cost a patient creates for the hospital. The challenges are therefore based on three factors, like remuneration for treatment, personnel and materials. All these factors vary, and adjusting one may affect the other considerably. Hence, an integrated database system or a data warehouse is needed that can perform accurate closed loop real-time monitoring and permitting multiple permutations and combinations being made available. The need for having a database management system for quick and easy retrieval, upgradation and editing of a large amount of patient data is of primary importance in hospitals. Now, a thrust is also being given to internal cost allocation within the hospital. Each department head is assigned the economic responsibility for his or her own department, becoming self-sufficient in budget allocation and management responsibilities. [sup][7],[8]
The World Health Organization defines Telemedicine as, "The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities." [sup][8] Telemedicine is the use of electronic information and communications technologies to provide and support health care when distance separates the participants. Telemedicine primarily refers to the use of telecommunication for the diagnosis and treatment of disease, provides healthcare expertise where there is none and improves the healthcare where there is some. [sup][9] A Telemedicine system includes hardware, software, medical equipment and communication link. It provides solutions or answers to patient's treatment in remote or inaccessible areas with fewer medical facilities. It is also possible nowadays to have a mobile telemedicine system using mobile and satellite communication.
In India, the telemedicine programs are actively supported by the following organizations:
*Department of Information Technology *Indian Space Research Organization *NEC Telemedicine program for North-Eastern states *Apollo Hospitals *Asia Heart Foundation *Different State government-run healthcare centers Telemedicine technology is finding vast use by private organizations like the Fortis group, Max Healthcare, Satyakiran, etc.
Need for Telemedicine in India
The heterogeneous geographical set-up of India (snow-covered mountains, hot deserts, islands, forests) effectively means that the population of India is spread out and not everyone has access to healthcare services round the clock. [sup][9]
The huge population of India makes the government's job more difficult in planning healthcare delivery systems and making facilities available for everybody at any place. [sup][9],[10]
Currently, specialists are concentrated in towns or cities as it provides them more lucrative opportunities in these regions. This makes it difficult for people living in remote places to get access to specialized healthcare services.
Some studies have shown that in the case of rural population the risk of death is twice that of urban patients with similar injuries. [sup][10]
Medical informatics is now considered as one of the important tools necessary to improve the quality of healthcare in many western countries. It has given physicians solutions to many problems they face in patient care. It covers a wide range of topics, including electronic medical record system, access to current information, clinical reminders, clinical decision support, electronic communication, patient education and self-management of chronic disease. [sup][10],[11] Both computers and information go hand in hand, and the role of computers will increase rapidly in further evolving the field of medical healthcare. Hence, an emphasis to supporting research of new and innovative technologies, information and knowledge management, improved communication between patients and providers, shared decision making, identifying and overcoming barriers to use of computers in healthcare and new challenges posed thereof must be focused upon. This will not only help the people directly involved with the healthcare industry but also those who aim to get associated and work to improve this area for the betterment of human health and society. [sup][11] For providing cheap and better healthcare facilities to the masses, the country must use and upgrade its medical centers with such technological tools to deliver the desired goods to the population at large.
Medical informatics can improve Mexico's public health system
