Research software system for electronic health records

Hiện nay, các bệnh viện ở Việt Nam vẫn đang sử dụng các bệnh án giấy truyền thống, và mới chỉ có 1 số ít bệnh viện đã sử dụng bệnh án điện tử (electronic medical records). trong bài nghiên cứu khoa học này, tôi có nghiên cứu về bệnh án điện tử cùng công nghệ tiêu chuẩn HL7, DICOM. các bạn thuộc lĩnh vực y tế, công nghệ có thể tham khảo.PSđây là 1 bài nghiên cứu hoàn chỉnh từ az bằng tiếng anh ạ

FINAL REPORT SCIENCE RESEARCH OF STUDENTS Project name: Research software system for electronic health records deployed in hospitals Code: < 23 > Group sciences: ĐỖ THỊ TÚ UYÊN NGUYỄN THỊ THANH THƯ Hanoi, May 1, 2018 FINAL REPORT SCIENCE RESEARCH OF STUDENTS Project name: Research software system for electronic health records deployed in hospitals Code: 23 Group sciences: Science and technology Researcher: ĐỖ THỊ TÚ UYÊN NGUYỄN THỊ THANH THƯ Class: MIS2016A Program: Management Information System Science advisor: Assoc.Prof NGUYỄN THANH TÙNG Hanoi, May 1, 2018 Form 03 VIETNAM NATIONAL UNIVERSITY, HANOI INTERNATIONAL SCHOOL LIST OF STUDENT PARTICIPATION IN RESEARCH No Full Name ĐỖ THỊ TÚ UYÊN NGUYỄN THỊ THANH THƯ Date of Birth 25/01/1998 20/10/1998 Class MIS2016A MIS2016A Responsibility Main Role Main Role INFORMATION ON STUDENTS MAINLY RESPONSIBLE OF RESEARCH A-Student I STUDENT PROFILE : Full Name : ĐỖ THỊ TÚ UYÊN Date of Birth : 25/01/1998 Place of Birth : Ha Nam Class : MIS2016A Course : 15 Addrest: Trinh Xa, Phu Ly City, Ha Nam provine Phone : 0919500641 Email : dothituuyen98hn@gmail.com II STUDY PROCESS (declaration of student achievement from year to now): * First year : Programme : Management Information System School : IS_VNU Graded learning outcomes : Academic pretty Summary Achievements:  Achieves the scholarship of school  GPA scores are good  Participante in mass activities organized by school  Participante in social activities such as charity, Blood donation, * Second year : (unfinished) B-Student I STUDENT PROFILE : Full name: NGUYỄN THỊ THANH THƯ Date of Birth : 20/10/1998 Place of Birth : Ha Nam Class : MIS2016A Course : 15 Address: Thanh Liem, Ha Nam provine Phone : 01636477106 Email : thanhthu2010ts@gmail.com II STUDY PROCESS (declaration of student achievement from year to now): * First year : Programme : Management Information System School : IS_VNU Graded learning outcomes : Academic pretty Summary Achievements:  Achieves the scholarship of school  GPA scores are good  Participante in mass activities organized by school  Participante in social activities such as charity, Blood donation, * Second year : (unfinished) Host Institution Officer of Research and Partnership Student mainly Development responsibility of research (signed and full name) * Student 1: ĐỖ THỊ TÚ UYÊN *Student 2: NGUYỄN THỊ THANH THƯ INFORMATION OF THEMES RESULTS General information: - Topic: Research software system for electronic health records deployed in hospitals - Researcher: Đỗ Thị Tú Uyên Nguyễn Thị Thanh Thư - Class: MIS2016A Program: MIS Year: 2016 Years of training: years - Science advisor: Nguyễn Thanh Tùng The goal of topic: On purpose, electronic medical records help to connect patient data from multiple sources and to provide applications and data so patients can understand and improve their health as well as help doctors access and follow up information of patients It also helps to investigate responsibility for problems arising from something In summary, electronic medical records help physicians and patients to be more proactive in protecting their health and diagnosing illness anywhere The novelty and creation: If the medical paper still has a lot of difficulties, now the electronic medical records have overcome almost all this disadvantages This technology is no stranger in the world but quite new when applied in the field of health in Vietnam This technology allows storage of a huge data volume and can be accessed anytime, anywhere, while ensuring the security of data Research outcomes: Learn the causes, current status, pros - cons and solutions for electronic medical records Learn about the medical market and suppliers in the country and in the world In addition, we also investigated how an electronic medical record system works and how to put it into practice Based on the fact, draw the fault of the hospital has been to improve electronic medical records on a better We have also improved our understanding as well as shared the results of this research for everyone to know Practical contributions: Applying information technology in the medical network is very important Medical standards such as DICOM for medical images and HL7 (health level 7) standards for data exchange The urgent need for a private network for health is inevitable According to the library's bookcase catalog, the standard for health information exchanges was developed by HL7 in 1987 with the first version After that, versions 2.0 and 3.0 are released and are currently being updated and developed For the 3x version, research in the world has built hundreds, thousands of newsletters, built the data formats as well as updated the reference model for HL7 With this standard structure, the characteristic health network allows each patient to have a complete record of all pathological and pathological profiles, prohibitions for prescribing medication, and so on This gives the patient clear information to better manage his or her health Scientists publication of the student research results or comments, evaluate of the establishments have applied the research results (If available): Hanoi, Date: 20/04/2018 Reviews of instructor on the scientific Student primarily responsible to contributions of students to implement implement the research the research (This section is recorded by Student 1: instructor): ĐỖ THỊ TÚ UYÊN Assoc.Prof NGUYỄN THANH TÙNG Student 2: NGUYỄN THỊ THANH THƯ Table of contents List of student in research……………….……………………………………………… ….3 Information of student…………………………………………………………………… ….4 Information of them result……………………………….……………………………………6 Table of figures………………………………….………………………………………… 10 Declaration…… ………………………………………….…………………………….….11 Acknowledgements………………………………………………………………………… 12 Introduction………………………………………………………………………………….13 Chapter 1: Overview of Electronic Medical Record and Paper…………………………… 15 1.1: Paper medical file ……………………………………………………………………….15 1.1.1 Definition……………………………………………………………………………….15 1.1.2: Features……………………………………………………………………………… 15 1.1.2.1: History of the formation…………………………………………………….……….15 1.1.2.2: Basic structure……………………………………………………………………….16 1.1.3: Access to medical records……………………………………………….……………17 1.1.4: Meaning of medical records………………………………………………………… 17 1.1.4.1: practical meanings……………………………………………………….………….17 1.1.4.2: Historical-Scientific Meaning………………………………………….…………….18 1.1.5 Difficult of medical paper………………………………………………………………18 1.1.5.1 For hospital leaders…………………………………………….…………………….18 1.1.5.2 For hospital staff…………………………………………………………………….19 1.1.5.3 For patients………………………………………………………….…………….….20 1.1.5.4 For health reporting system - statistics - disease test………………….……….……21 1.1.5.5 For health insurance policies………………………………………………….….….21 1.2: Electronic Medical Record …………………………………………………….…….….22 1.2.1: Birth, definition……………………………………………………………………….22 1.2.2 Overview of utility, properties of electronic medical records…………………………23 1.2.3: Technology with Electronic Medical Record…………………………………… ….24 1.2.3: Factors that an electronic medical record must have………………………………….24 1.2.4: Conditions for implementing an electronic medical record………………….……….26 Chapter 3: The Emergence of Electronic Medical Record and how it works, its role……………………………………………………………………………………………27 3.1: Situation at home and abroad…………………………………………………………….27 3.2: Parts of an electronic medical record and their concepts…………………….………….27 3.3: Operating Procedures of Electronic Medical Records……………….………………….31 3.3.1: Collection and processing of input data……………………………………………….32 3.3.1.1: Build the database……………………………………………………………………32 3.3.1.2: Database Input……………………………………………………………………….34 3.3.2: Intermediaries and interfaces of HIS with other systems…………………… ….……35 3.3.3: Export outputs and medical record keeping…………………….………….…… ….44 3.3.3.1: Output……………………………………………………………………….… …44 3.3.3.1.1: Receipt - charge - Health insurance……………………….……………… ….…44 3.3.3.1.2: Clinic module……………………………………………………….……,.….45 3.3.3.1.3: Image Diagnostics Subsystem…………………………………………….… ….46 3.3.3.1.5: Outpatient Pharmacy…………………………………………………… … ….46 3.3.3.1.6: Residential management module……………………………………… ….46 3.3.3.1.7: Hospital pharmacy management system……………………………… ….… ….47 3.3.3.1.8: Reporting - statistics - data mining…………………………………….…….….…48 3.3.3.2: Storage and Preservation…………………………………………….………… …48 3.3.3.3: Situation of collecting electronic medical records into archives….…………… …48 3.3: Advantages and Disadvantages of Electronic Diseases………………….………… …50 3.3.1: Advantages…………… ….…………………………………………………….……50 3.3.2: Limitations………………………………………………………………….…….……53 Chapter 4: Comprehensive Solution and Enhance Efficiency in the Storage and Management of Electronic Medical Record…………………………………….………………………….55 Conclusion and Recommendation……………………………………………………………57 References…………………………………………………………………………………….59 Appendices…………………………………………………………… …………………….62 Table of Figures FIGURE 1: DIAGRAM OF THE FORMING A GENERIC MEDICAL RECORD FIGURE 2: DIFFICULT OF MEDICAL PAPER FOR HOSPITAL STAFFS FIGURE 3: DIFFICULT OF MEDICAL PAPER FOR PATIENTS FIGURE 4: DIFFICULT OF MEDICAL PAPER FOR HEALTH REPORTING SYSTEM - STATISTICS - DISEASE TEST FIGURE 5: FUNCTION OF HIS FIGURE 6: A GENERAL OPERATIONAL MODEL OF AN ELECTRONIC MEDICAL RECORD FIGURE 7: EXAMPLE OF DATABASE INPUT IN EMR FIGURE 8: INTERMEDIARIES AND INTERFACES OF HIS WITH OTHER SYSTEMS FIGURE 9: DOCTORS CAN ACCESS ONLINE FIGURE 10: DOCTORS CAN EASILY MANAGE PATIENTS UNDERGOING TREATMENT FIGURE 11: DOCTORS CAN EASILY MANAGE PATIENTS UNDERGOING TREATMENT FIGURE 12: TYPICAL HOSPITAL IT SYSTEMS FIGURE 13: THE LIST OF PATIENTS IN SYSTEM FIGURE 14: SYSTEM OF DICOM STANDARD FIGURE 15: THE RELATIONSHIP OF RIS AND PACS FIGURE 16: SUBCLINICAL INFORMATION FOR A PATIENT FIGURE 17: PACS SYSTEM FIGURE 18: DICOM FILE FORMAT FIGURE 19: HOSPITAL FEES FIGURE 20: MEDICINE MANAGEMENT FOR A PATIENT Declaration I pledge that: This report is our research product 10 • Service management functions: Every patient admitted to the hospital has access to medical services • Functional resident management: This is a complex system Prescription drugs will be synthesized and transferred to pharmacies; Importing drugs from drug stores to patients for redistribution 3.3.3.1.7: Hospital pharmacy management system • Drug storage system: including the warehouse with the function of purchasing and distributing drugs for retail stores; Retail stores are classified as drug stockpiles • Inpatient drug system: used to synthesize drug requirements, sent to the warehouse, received medicine and distributed to the patient • Cabinets: At the emergency department, the ward has a wardrobe to manage the medication needed immediately • Medical and biological materials management system: to manage medical supplies, oxygen, hematologic, chemical The picture below is an example of medicine management for a patient: Figure 20: Medicine management for a patient 47 3.3.3.1.8: Reporting - statistics - data mining • All departmental data is recorded and exported into national standardized reporting systems, into separate hospital records • Data systems of software will become invaluable resources for statistics, secondary research 3.3.3.2: Storage and Preservation: The department wants patients to be discharged from the hospital must send a request to the Department of Science and Technology The STI will check the patient's medical records before accepting the patient's discharge After the release of the electronic medical records, the medical records will be automatically transferred to the General Plan and without the permission of the general planning department, the medical records cannot be opened In short, with the help of science and technology, such as opening electronic medical records, gathering documents into electronic medical records; Arrange the documents in the medical records; Electronic medical record cataloging; An electronic medical records archive is a sequence of software linked and output from different modules and automatically transferred to electronic medical records on the machine But now the electronic signature authentication has not been implemented and the legal corridor is not allowed so the legal status is not guaranteed so still have to print to ensure legal and archived records attached paper 3.3.3.3: Situation of collecting electronic medical records into archives Medical records are medical, medical and legal documents; Each patient has only one medical record at each medical examination and treatment at medical examination and treatment establishments And collecting the lake Electronic medical records in the store also have specific regulations: • Submitters of documents: Medical records of inpatients, outpatients, referral and death must be completed administrative procedures according to the regulations into the hospital transferred, 48 transferred to the hospital, then transferred to the department of general plan archive regulations Even this is also software automation • Electronic records filed: Medical records are automatically integrated into the machine so that records of inpatient, outpatient, referral and death records are automatically transferred to the General Plan room for preservation of the discharge order • Time to deposit: The patient is discharged within 24 hours, the department must complete the administrative procedures of the medical records according to regulations, transferred to the general planning department The General Planning Department checks the implementation of the regulations on medical records of the Directorate for approval and transfer of archives It's about regulation But now in the hospital due to software applications should complete the medical records quickly in a few seconds When prompted to discharge from hospital, the electronic medical records were transferred to the General Planning Department The head nurse then submitted the medical records and sent them to the General Planning Department to complete the payment procedures records • Application procedures: When prompted to discharge from hospital, the electronic medical records were transferred to the General Planning Department The head nurse then submitted the medical records and sent them to the General Planning Department to complete the payment procedures records The General Planning Department checks the implementation of the regulations on medical records of the Directorate for approval and transfer of archives This stage of regulations is so, but in practice due to busy work from the director to retreat period about days (As in Vietnam-Soviet Friendship Hospital) It means that the General Planning Office must check the formalities of the file in accordance with the regulations or not If the patient's medical records have not been recorded in accordance with the regulations, the administrative nurse's requirements will be fulfilled 49 3.3: Advantages and Disadvantages of Electronic Diseases 3.3.1: Advantages The growth of information technology today has created a solid foundation for the development of a complete electronic medical records system In recent years, many effective clinical systems have been put into use Clinical systems associated with electronic medical records have a lot in common It can be seen first of all that they maintain a very large data dictionary to define the contents of electronic medical records In addition, all patient records recorded in electronic medical records are linked to the time taken to make them based on the history of the care process These electronic medical record and data retrieval systems work in a flexible way, offering a research tool that uses electronic medical record data Many difficulties, hindrance to previous technology for the development of electronic medical records now seem to have disappeared or been resolved However, although there is no need for a technological breakthrough, it is the growth of new technology products such as laptops, voice recognition, handwriting recognition, etc necessary to build a complete electronic medical record Many technologies have had to be tested in real-world situations; and many of them have proven to be beneficial in other areas, but not in the healthcare sector With the rapid development of the necessary technologies, technological standards have also been developed, tested and supplemented so that electronic medical records can perform its full function at the macro level or micro Standards are needed to facilitate the exchange of data, so that clinical data must be transmitted on the computer network or collected and analyzed to support decision making important Current security technologies are also a boon for clinical data to become secure, more reliable In general, if you compare only the conventional cardiovascular disease, you will notice some differences as follows: Medical records paper Difficult to access parts of the geographic Electronic medical records Access privilege, at the same time distribution profile Passive: cannot start the action Active: can initiate certain actions depending on the data 50 Presentation of non-normative Information storage is more standardized, information more clear; It allows for interlinking between departmental systems and can lead to improvements in quality assurance Type link "manual" "Expand" links with external health care providers The risk of lack of information is greater Can increase the completeness by (less check on full completion checking additional structures when information) entering data Presentation of data is not flexible (only a Flexible presentation of data across single representation) multiple "angles" to meet needs (on an individual / patient basis or as a whole) Spend plenty of time researching financial An excellent foundation for managing and or medical research directing financial and medical research There is no risk of technical failures The risk of technical failure and non-use is dependent on the substance hardware / software Lower cost (only the initial cost is not the Higher costs for installation, staff training full cost) and system management Doctors manually enter data manually There may be resistance and anxiety among doctors for entering data into the computer Confidentiality; easy to access Difficult to maintain security and reliability (tracking and logging) Difficult to access parts of the geographic Access privilege, at the same time distribution profile Passive: cannot start the action Active: can initiate certain actions depending on the data 51 Presentation of non-normative Information storage is more standardized, information more clear; It allows for interlinking between departmental systems and can lead to improvements in quality assurance Type link "manual" "Expand" links with external health care providers The risk of lack of information is greater Can increase the completeness by (less check on full completion checking additional structures when information) entering data Presentation of data is not flexible (only a Flexible presentation of data across single representation) multiple "angles" to meet needs (on an individual / patient basis or as a whole) Spend plenty of time researching financial or medical research An excellent foundation for managing and directing financial and medical research There is no risk of technical failures The risk of technical and non-technical failures depends on the quality of the hardware / software Lower cost (only the initial cost is not the Higher costs for installation, staff training full cost) and system management Doctors manually enter data manually There may be resistance and anxiety among doctors for entering data into the computer Confidentiality; easy to access Difficult to maintain security and reliability (tracking and logging) 3.3.2: Limitations  Technology: • Medical data is large, transmission speed is high, accurate and no interference 52 • Many systems exist • There is no uniform standard of communication between hospitals • Many medical technologies used in hospitals are not modern or cannot be linked together: xray film, digital x-ray, electrocardiogram, cardiac electrocardiogram • Medical technology is growing rapidly  People: • Familiarize the old process, afraid to change • Not used to computers, afraid to study • Health workers are very busy so it is very difficult to get information, collect information • For unstable requirements • Information technology workers rarely cooperate: avoid responsibility, avoid additional work • Opposition to competition • Change the process • Change of receipt  Society: • Changes in the health law, health insurance • Changing the rules of personnel management, salary • Changes to the health information system • Change of process, report form • Changes in organizational structure 53 Chapter 4: Comprehensive Solution and Enhance Efficiency in the Storage and Management of Electronic Medical Record In order to diagnose the patient, we must use a lot of information on medical history, diagnosis results, diagnostic information, visual information (X-rays, CT, MRI, ), even Databanks contain knowledge that supports the decision-making process Based on the application of electronic medical records, we still have difficulties that most hospitals still cannot solve This chapter we have studied and studied the materials to make the best practical solutions for electronic medical records Technical options: With the equipment and modern equipment has given the hospital a number of problems that need information technology to solve it is: - How can we store all the information, patient records, medical images from the machine in a scientific way? The purpose is to be able to build a medical data bank for data mining, diagnosis, treatment and study and research for physicians It is also part of an important legal record of retrieving information - Standardization of data according to a common standard Build the system to easily exchange information, images, data between medical devices in the department To bring comfort and accuracy to the doctor in the diagnosis and treatment of disease quickly and effectively - How to exchange data through the Internet for remote consultation How to share information, medical data between hospitals in the area Serving for directing the line, reducing patient load from lower level hospitals Applicable technical standards The information system supporting medical diagnosis is developed in the direction of: - Medical management standards in the world: ICD, HL7, HIS, RIS, ERC, DICOM - The medical report forms system of the Ministry of Health of Vietnam Accessories are made to ensure that they are in good working order and good performance in 3-5 years However, to improve performance and data security, we offer the following solutions: Increase the number of CPUs of the application/database server from to Increase the application/database server ram capacity from to 16 GB 54 • Classroom equipment (2 servers running in parallel) for increased data security • Ensure stable operation 24/7 Model information system supporting medical diagnosis Figure 22: Model information system supporting medical diagnosis The design and installation of the cluster in the medical system should meet the following requirements: - High availability requirements Network resources must be available in the highest capacity to provide and serve end-users and minimize unwanted system downtime - High-reliability requirements High reliability of the cluster is understood as the ability to reduce the frequency of occurrences and to improve fault tolerance of the system - scalability requirement The system must be easy to upgrade and expand in the future Extensive upgrades include adding computers and devices to the system to improve service quality, as well as adding more users, adding applications, services, and additional resources The above requirements are referred to as RAS (Reliability-Availability-Scalability), systems that meet these three requirements are referred to as RAS (separate from Remote Access Service as remote access service) 55 Conclusion and Recommendation We have seen very clearly that the transition from paper medical to electronic medical records is not the only motivation for the evolution of personal health records A small but powerful push comes from the patient at the center when they are requesting access to and checking their health information at any time and in a simple, easy-to-do way The information system has been developed extensively today and the thesis has met that The research focuses on promoting and applying IT in hospitals under Ministry of Health in prescribing electronic medicines, electronic patient records, and hospital management, establishing a support system for diagnosis To reduce the burden on patients, to reduce the overload of hospitals at the central level The report was developed for the treatment of eczema as a legal document on medical activity in patients Electronic medical records support research: clinical, health care, drug effects Different doctors look at electronic records for further treatment according to the course of the disease Human beings are following The notes, notes of previous doctors such as drug allergies, complications arising are doctors to know later and avoid harmful interventions for patients With the data saved Sometimes, with only one case, the physician can discover many interesting things for scientific research Hospital data after a period of accumulation will become the treasure of the doctoral students Electronic medical records play an important role in the training and research and also makes sense for the management and operation of the hospital in general Electronic medical records combined with a medical diagnostic system to transfer all the information: test results, X-ray images, magnetic resonance, endoscopic results, ultrasound, general diagnostic results and data Treatment includes both examination and medicine, surgery, hospital fees into structured data Electronic medical records are stored centrally and circulated directly to the doctors of the relevant departments Electronic medical records can be transformed into a multimedia form that is often used in remote imaging Electronic medical records can be exchanged directly with hospitals and related organizations via the Internet to support medical consultation [3] Patients with the desire to quickly get rid of the disease may be treated in many other places each other, even go abroad for treatment The medical records of the patients are very necessary to carry With electronic medical records, patients can access the hospital website to copy their health information as a reference for new treatment sites Widespread use of 56 Informatics in Medicine, this article suggests diagnostic departments Imagine photos without film and hospitals not need paper To this, hospitals use digital devices, computers that are connected to one another in large networks That is also the last thing we want to aim for in the near future 57 References 1) Cambridge University, UKHard Vs Soft Power Foreign Policy Strategies in Contemporary International Relations 2) Chung, K (2012, January 22) Americanization of the World: Undeniable Reality? 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REPORT SCIENCE RESEARCH OF STUDENTS Project name: Research software system for electronic health records deployed in hospitals Code: 23 Group sciences: Science and technology Researcher: ĐỖ THỊ... THANH THƯ INFORMATION OF THEMES RESULTS General information: - Topic: Research software system for electronic health records deployed in hospitals - Researcher: Đỗ Thị Tú Uyên Nguyễn Thị Thanh Thư... 2018 12 Introduction Topic: Research software system for electronic health records deployed in hospitals Number of pages: Major: Science and Technology Date: May 1, 2018 Researcher: ĐỖ THỊ TÚ UYÊN