Patient Records and Usability - Uppsala University · Informationsteknologi Institutionen för...
Transcript of Patient Records and Usability - Uppsala University · Informationsteknologi Institutionen för...
Patient Records and Usability
Rebecka Janols 2010-11-05
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Last lecture The patients’ way through the health care is
called care process. Medical records is a systematic documentation
of a patient's medical history and care. Physician, nurse, psychologist, physiotherapist,
welfare officer are legally required to document. The medical record can be time,-problem,-
source oriented. Patient Data Act : improve patient security and
protect sensitive data.
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Problems with EPR 1. User interface 2. Safety 3. Terminology 4. Communication
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Problem 1: User interface Overview of information Different type of information should be
presented: text, numbers, images, voice Different ways for data input:
Free text Structured Voice
Cosmic
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TakeCare
TakeCare – “to do”
Take Care – “to do”- at this unit
TakeCare – “to do” with this patient
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The patient card
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My master thesis
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Health issue patient overview
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Health issue overview
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Problem 2: Safety Secrecy Accessibility Correctness Traceability
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Problem 3: Terminology Confusion about the meaning of words.
Different words for the same thing Same word for different things Free text
Different terminology between different roles.
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Anamnesis and Status Anamnesis: Physician: patient history in health care Nurse: information about the patient
before the patient comes to the care
Status: Physician: objective findings Nurse: how the patient feels today
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Care process vs. reality • Care process is a simplified model of the
reality • Reality is more complex • The systems support the care process not
the reality.
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Coding and Classification The computer understand Same in different countries Easier to make statistics The structure and level of details of the
classification system depend on it’s purpose. Many different coding and classification. ICD 10: Diseases and Related Health Problems ICF: International Classification of Functioning,
Disability and Health SNOMED-CT: Complete medical terminology
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Problem 4: Communication Information in many systems
Different architecture Different information structure
Integration & interoperability Technical interoperability Semantic interoperability
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Communication • 36 different kind of systems at
Akademiska Hospital • “National quality register”, 71 in Sweden.
(ex. Different kind of cancers, diabetes, Asthma and trauma)
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Can you think of any other problems?
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Trends…. NPÖ – National Patient Overview European Patient Overview Medical account so the patient can get
access to her own medical record.
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Summary The problem with the computer based medical
records are: User interface Safety Terminology Communication