e-Health Systems

Theory and Technical Applications

Joel J.P.C. Rodrigues, Sandra Sendra Compte, Isabel de la Torre Díez

• Publisher: ISTE Press - Elsevier
• Year: 2016
• Print ISBN: 9781785480911
• eBook ISBN: 9780081012055
• Topic: Informatica
• Subtopic: Database

e-Health Systems: Theory, Advances and Technical Applications offers a global vision of all the parties involved with e-health system deployment and its operation process, presenting the state of the art in major trends for improving healthcare quality and efficiency of healthcare management.The authors focus on ICT technologies and solutions for health management and healthcare applications, specifically emerging ICT to help reduce costs and improve healthcare quality, and healthcare trends in consumer empowerment and information-rich "Smart Care", with ubiquitous care access from anywhere, at any time, by any authorized person(s) when needed.Split into two parts, this book provides a comprehensive introduction to the concepts of e-health and delves into the processes carried out to store information, as well as the standards that are used; the authors explore applications and implementation of e-health systems, explaining in depth the types of wireless networks and security protocols employed to convert these systems into robust solutions avoiding any kind of data corruption and vulnerabilities.- Presents e-Health from implementation at the physical level, to the communication level between different systems and sensors- Considers all process security methods and the most relevant related standards- Suitable for students, academics, researchers, and professionals involved in applications to improve health management and eHealth systems

Part 1

Electronic Health Records: Standards and Other Initiatives

1

Electronic Medical Records and Their Standards

Abstract

Medical records are considered the quintessential clinical document. They are used as information support generated by the healthcare team, and are used as a transmission vehicle between the various team members who treat patients in another place or time. The traditional functions of medical records are care, teaching and research. From these, others have been developed which are closely related. These include:

– assistance: it is basically a document to assist care. Its main mission is to collect all pathologically relevant information on patients in order to derive the correct diagnosis or treatment in his/her case;

– teaching: each medical record should reflect the correct way of treating each clinical case, explaining exploratory and therapeutic decisions taken;

– clinical research: it establishes the precise mechanisms for locating medical records relating to a particular disease or a particular treatment, and it can be used as a source of knowledge of clinical activity itself;

– epidemiological investigation: it makes reference to research that relates to the causes of a disease and the influence of these over the emergence of disease;

– clinical management and care resource planning: it serves in clinical management, evaluation of local resource use and the planning of future investment;

– documentary legal evidence: this is a documentary account of the care and treatment provided;

– care quality control: medical records enable the assessment of scientific and technical objectives.

keywords

Benefits; Electronic health records (EHRs); Goals; Information society; Medical records; Requirements; Standards

1.1 Introduction

Medical records are considered the quintessential clinical document. They are used as information support generated by the healthcare team, and are used as a transmission vehicle between the various team members who treat patients in another place or time. The traditional functions of medical records are care, teaching and research. From these, others have been developed which are closely related. These include:

– assistance: it is basically a document to assist care. Its main mission is to collect all pathologically relevant information on patients in order to derive the correct diagnosis or treatment in his/her case;

– teaching: each medical record should reflect the correct way of treating each clinical case, explaining exploratory and therapeutic decisions taken;

– clinical research: it establishes the precise mechanisms for locating medical records relating to a particular disease or a particular treatment, and it can be used as a source of knowledge of clinical activity itself;

– epidemiological investigation: it makes reference to research that relates to the causes of a disease and the influence of these over the emergence of disease;

– clinical management and care resource planning: it serves in clinical management, evaluation of local resource use and the planning of future investment;

– documentary legal evidence: this is a documentary account of the care and treatment provided;

– care quality control: medical records enable the assessment of scientific and technical objectives.

Medical records should be unique to each person, accumulate all their medical information and be integrated, so that they contain information on the all of the episodes of contact and disease.

The current holder of the medical record can present a number of problems relating to the information contained in it such as increased provider time, computer down time, lack of standards and threats to confidentiality [SEI 03].

The usual mass of documents leads to disorganization and fragmented information, with often poor success when trying to recover information in a rational and logical manner. The main problems with paper records are:

– the lack of uniformity in the documents causing uncertainty about their content;

– the illegibility of certain information contained in medical records primarily from handwritten documents;

– the changeability of information where existing support does not have access to mechanisms to ensure that their content is not altered by different users;

– questionable availability, and therefore accessibility, to information contained within the records. Technical support and level of access also vary. It is not possible for two or more people from different places to access the same record simultaneously;

– errors in partially stored documents (even in documents that are fully stored) that cause loss of value because of the lack of availability of the information contained therein;

– the problem of space and the personnel needed to handle it;

– technical difficulties in ensuring the anonymization of patient identifying data when using clinical data for analysis and research purposes to meet current data protection legislation [FAL 01];

– concerns over confidentiality because control to access to medical records cannot be ensured;

– the deterioration of supporting documentation and the risk of loss caused by water or fire caused by accidents or other events.

These problems are easier to solve with the use of electronic health records (EHRs), where its deployment implies no distortion in clinical activity. The computerization of the clinical history as well as offering a possible solution to the above-mentioned problems, EHRs provide the opportunity to integrate clinical information and to review the organization of services and professionals [MON 03].

Historically, one of the biggest challenges for healthcare professionals has been sharing information from different sources. With the growing trend toward EHR utilization, the need to achieve this goal has become urgent.

Computing and the emergence of new technologies are tools that help society to improve clinical applications [ROD 13a, FER 12]. The use of a simple, reliable and portable solution is essential to allow communication across different platforms. The structure and format of these electronic reports allow physicians the option to print them but also the ability to access the patient’s medical record in a fast and simple way. It is assumed that a successful digital health information system must include information from the following systems [SEI 03]:

– health card database;

– current medical record, wherever it was generated;

– access to departmental clinical systems such as clinical analysis laboratory or diagnostic imaging services;

– health promotion and disease prevention programs;

– information on h...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Preface
• Introduction
• Part 1: Electronic Health Records: Standards and Other Initiatives
• Part 2: Emerging e-Health Technologies and Applications
• Bibliography
• Index