“Victor Babes” UNIVERSITY OF MEDICINE AND PHARMACY TIMISOARA DEPARTMENT OF MEDICAL INFORMATICS AND BIOPHYSICS Medical Informatics Division / 2005

HEALTH INFORMATICS MEDICAL INFORMATION SYSTEMS COURSE 13

1. MEDICAL INFORMATION 1.1. TYPES OF ACTIVITY1.1. TYPES OF ACTIVITY –a. MEDICAL ACTIVITIES (CONSULTATIONS, VISITS) DIAGNOSINGDIAGNOSING –DATA - MEDICAL OBSERVATION, INVESTIGATIONS –KNOWLEDGE - EDUCATION, ETC THERAPY / FOLLOW-UPTHERAPY / FOLLOW-UP NURSINGNURSING

b. LOGISTIC SUPPORTTb. LOGISTIC SUPPORTT –ADMINISTRATION –ACCOUNTING c. SOCIAL CONTEXT FRAMEc. SOCIAL CONTEXT FRAME –MEDICAL DATA CENTRALISATION d. MEDICAL EDUCATION (CME)d. MEDICAL EDUCATION (CME) –STAFF –PATIENTS e. MEDICAL DOCUMENTATIONe. MEDICAL DOCUMENTATION f. MEDICAL RESEARCHf. MEDICAL RESEARCH

1.2. INFORMATION FLUX STRUCTURE1.2. INFORMATION FLUX STRUCTURE –a. SCHEME –b. DATA TYPES –c. LEVELS: PRIMARY CAREPRIMARY CARE SECONDARY (SPECIALISED) CARESECONDARY (SPECIALISED) CARE HEALTHCARE UNITSHEALTHCARE UNITS CENTRAL LEVELS :CENTRAL LEVELS : –COUNTY HEALTH DEPARTMENTS –NATIONAL LEVEL: HEALTH MINISTERY –INTERNATIONAL BODIES: WHO

CYCLES OF MEDICAL INFORMATION FLOW

“Allied” Professionals in Healthcare

1.3. DEFINITIONS1.3. DEFINITIONS –a. INFORMATIONAL SYSTEM = ensemble of structural units exchanging information between them –b. INFORMATION SYSTEM = that part of the informational system which comprises computer use

2. PRIMARY CARE INFORMATION SYSTEMS 2.1. ACTIVITIES:2.1. ACTIVITIES: –PROFESSIONAL PRACTICE CONSULTATIONS, HOME VISITS,CONSULTATIONS, HOME VISITS, CHRONIC PACIENTS FOLLOW-UPCHRONIC PACIENTS FOLLOW-UP EMERGENCIESEMERGENCIES –MEDICAL DOCUMENTATION –MANAGEMENT

MODULES - PRIMARY CARE Basic module Medical module Programming module Pharmacy module Financial module Communication module Future development

2.2. PRIMARY CARE I.S. MODULES 1) BASIC MODULE:1) BASIC MODULE: –a. DATA: ALL PATIENTS RECORDSALL PATIENTS RECORDS “DEMOGRAPHIC” DATA“DEMOGRAPHIC” DATA (including insurance data) (including insurance data) DATA GROUPING ON “FAMILIES” (households)DATA GROUPING ON “FAMILIES” (households)

–b. ADMINISTRATION REGISTERS: visits, consultations, laboratory tests, etcREGISTERS: visits, consultations, laboratory tests, etc SIMPLE FINANCIAL DATA (bills)SIMPLE FINANCIAL DATA (bills) VARIOUS CENTRALIZED RECORDS (drugs, supplies, etc)VARIOUS CENTRALIZED RECORDS (drugs, supplies, etc) –c. COMPUTER OPERATIONS DATA PROTECTIONDATA PROTECTION PARTITION WORKPARTITION WORK DATA BACK-UPDATA BACK-UP

2) MEDICAL MODULE EPR - ELECTRONIC PATIENT RECORD CPR – COMPUTER-BASED PATIENT RECORD EHR - ELECTRONIC HEALTH RECORD

PACIENT HEALTH RECORD a. PAPER BASEDa. PAPER BASED –ADVANTAGES / DISADVANTAGES EASY TO CARRY, EASY TO “BROWSE”EASY TO CARRY, EASY TO “BROWSE” LOW COST, HIGH FIABILITY (NO “SYSTEM FAILURE”…)LOW COST, HIGH FIABILITY (NO “SYSTEM FAILURE”…) FAST FILLING INFAST FILLING IN LIMITED ACCESIBILITY (ONE PLACE)LIMITED ACCESIBILITY (ONE PLACE) b. ELECTRONIC FILEb. ELECTRONIC FILE –ADVANTAGES / DISADVANTAGES ACCESIBILITY: FROM SEVERAL PLACES, BY SEVERAL PERSONSACCESIBILITY: FROM SEVERAL PLACES, BY SEVERAL PERSONS EASY TO READ, FAST INFORMATION RETRIEVALEASY TO READ, FAST INFORMATION RETRIEVAL GOOD SUPPORT FOR DATA ANALYSIS AND DECISIONGOOD SUPPORT FOR DATA ANALYSIS AND DECISION REQUIRES SPECIALIZED PERSONNELREQUIRES SPECIALIZED PERSONNEL SLOWER FILLING INSLOWER FILLING IN HIGHER COSTHIGHER COST

EHR STRUCTURE EHR STRUCTURE IDENTIFICATION DATAIDENTIFICATION DATA EVENTS: consultation, admission, surgery, radiography…EVENTS: consultation, admission, surgery, radiography… –(time function) –COMPONENTS – ACTIONS OBSERVATIONS: anamnesis, lab results, investigations – signals, imagesOBSERVATIONS: anamnesis, lab results, investigations – signals, images DECISIONS: diagnosisDECISIONS: diagnosis INTERVENTIONS, THERAPY: prescriptions, referralsINTERVENTIONS, THERAPY: prescriptions, referrals RELATIONSRELATIONS ENCODINGENCODING –NOMENCLATURES: WHO, ICD9-10, ICPC, SNOMED

3) SCHEDULING MODULE (integrated in medical module)3) SCHEDULING MODULE (integrated in medical module) –SCHEDULE REGISTER –LETTER EDITING 4) PHARMACY MODULE4) PHARMACY MODULE (rural / remote health units etc) (rural / remote health units etc) –DRUG RECORDS –SUPPLIES –SPECIFIC FEATURES (free treatments)

5) FINANCIAL MODULE5) FINANCIAL MODULE –PATIENT BILLS –PAYROLLS –EXPENSES BILLS –FINANCIAL CORRESPONDENCE 6) COMMUNICATION MODULE (Internet, fax, , hospital comm. etc)6) COMMUNICATION MODULE (Internet, fax, , hospital comm. etc) 7) FUTURE DEVELOPMENTS (expert systems etc)7) FUTURE DEVELOPMENTS (expert systems etc)

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