Proceedings the 10th students scientific research conference

Proceedings the 10th students scientific research conference Research software system for electronic health records deployed in hospitals Group sciences: Đỗ Thị Tú Uyên Nguyễn Thị Anh Thu Class: MIS016A Science advisor: Assoc.Prof Nguyễn Thanh Tùng 330 Proceedings the 10th students scientific research conference The necessary of topic In the medical information system, especially the hospital information system, the storage of patient information, books and paperwork is very important, careful and time-consuming Large numbers of archival records, such as archives, are too timeconsuming, difficult to find, especially information sharing between faculties or hospitals with patients is almost impossible In addition, when the patients go to the examination must bring old records, papers and medical records are very inconvenient and time consuming for doctors and medical staff to check the health status of the patient In Vietnam, technology 4.0 is growing so the birth of electronic medical records is extremely urgent and practical It makes it easier to diagnose, statistics and scientifically research the specialty, reduce the annual storage of hospital records, and help patients and clinicians improve the effectiveness of the clinic treatment and health care for patients As a result, nowadays, hospitals in the country have gradually shifted to the collection and storage of electronic medical records The goal of topic Health care is a matter of concern in this day However, the annual cost for it is very large, especially in the management of records and keep the data is not a small number In addition, the manual management of medical records has many shortcomings in the storage, lookup, preservation and confidentiality of information This is a push for electronic medical records (EMR) to appear EMR makes it easier to store patient information, doctors and patients better understand the information In general, the implementation of electronic medical records in Vietnam is inevitable, consistent with the development trend of electronic drugs in the country and internationally To implement EMR is a process of continuous struggle, persistence and difficulty, must invest many resources We should look at the situation at home and abroad, the constraints To draw lessons and bring the system to perfection, apply it to the real world soon 331 Proceedings the 10th students scientific research conference Research questions, methodology and scope of research  Research questions: In general, we have followed a few key questions below to make this report: - What is electronic medical records? - What is situation of electronic medical records at home and abroad? - What are advantages and disadvantages of electronic medical records? - How difficult and how to overcome?  Methodology: Firstly, the research team studied many documents on the network of hospitals in the world such as China, Australia, USA to be able to get a better overview of the innovation and development of the medical Old medical records and the problems revolve around it The research team combines various methods such as integrated analysis, descriptive statistics, and so on, through the observations and experiences of each team member, to discuss the advantages and disadvantages of each Medical records with electronic medical records, causes - actual situation and solutions That is using the comparison method Through the research methodologies and surveyed sites, the research team can draw on the experience of paper medical records and how EMR can be put into operation, so that it can bring many benefits to the people, not expensive but modern and catch up the trend of the world  Sphere of analysis: Due to time constraints as well as busy learning, here we only mention electronic medical records in general and the situation in some hospitals in the North as a number overseas hospitals through the internet Facilities and the difficulty of the researching process 4.1 Facilities At present, the research team uses only the facilities of the science and technology department, the center for scientific research and the application of information technology Moreover, the new group only visited the technology model of some hospitals and clinics 332 Proceedings the 10th students scientific research conference 4.2 Difficulty Firstly, the research time is limited and due to busy learning, the group cannot study deeply about the topic Secondly, the physical facilities for research are limited In addition, the group also had limited access to hospitals In other words, the scope of the research group is limited and mainly referred to through the media, television, internet, etc Chapter 1: Overview of Electronic Medical Record and Paper 1.1: Paper medical file 1.1.1 Definition: Under Clause 1, Article 59 of the Law on Examination and Treatment (No 40/2009 / QH12) passed by the 12th National Assembly of Vietnam on November 23, 2009, provides: "Medical records are medical documents legal and legal; Each patient has only one medical record at each medical examination and treatment at medical examination and treatment establishments " According to foreign sources, "dictionary.com" states: The medical record is "a written document of the length of the medical examination and treatment of a stroke, including a medical history and patient complaints., the clinical outcome of the doctor, the results of diagnostic tests and procedures, drugs and procedures Medical records are treated as a brochure containing a variety of information and aspects of the patient From personal information such as name, date of birth, address, living situation, work, to illness, biography, From that, medical records can be viewed as There are two main types of patients: primary and secondary patients In particular, the main disease plays a role directly related to the patient's medical examination and treatment such as doctor's examination, diagnosis, tests, prescriptions, follow-up examination can also be considered as part of the main medical records However, it is closely related to the hospital, not patients such as personal information, health insurance, hospital fees, hospital admission procedures, patient support administrative In summary, medical records are an important part of the hospital information management system and have important responsibilities in the administrative and 333 Proceedings the 10th students scientific research conference clinical management Accurate, accurate, systematic records will help to make the diagnosis, treatment, prevention, scientific research or training more effective It also helps to assess the quality of treatment, morale, responsibility and ability of health staff in particular and the hospital in general 1.1.2: Features 1.1.2.1: History of the formation Decision No 4069/2001 / QD-BYT, September 28, 2001, of the Ministry of Health promulgating forms of dossiers for medical examination and treatment establishments (collectively referred to as hospitals) public, private, private, foreign-invested medical examination and treatment establishments Particularly leading specialized hospitals, due to intensive requirements, may add some necessary contents to the samples after obtaining the Health Minister's consent 1.1.2.2: Basic structure There are 24 medical records for general hospitals Each type has its own structure but basically consists of the main parts such as: • Medical records The size is 27x53 cm The front of the cover shows the patient information as well as the type of illness and some information at the doctor's visit The back cover is medical records • Documents and contents inside the medical record Include a general information about the patient, the status of the examination, the administrative papers, the results of the test, the standard meeting card, treatment card, family guarantee, etc • Summary of the medical records The important thing is that all the papers inside the medical records must have the signature, title, and seal of the people involved in the disease Especially the primary physician We can refer to the process of forming a medical record set by the Ministry of Health: 334 Proceedings the 10th students scientific research conference Figure 51: Diagram of the forming a generic medical record 1.1.3: Access to medical records The question is: Who has the right to see the medical records? • A medical record is the property of the hospital or the physician This is a confidential information of the patient and cannot be distributed without his or her permission • All patients have access to their records and get copies of those records • The legal representative of the patient has the right to such records as long as the patient has signed a notice with the request of the representative at law • Other health care providers have the right to keep a record of the patient if they are directly involved in the care and treatment of the patient • Parents of minors also have access to patient records • Medical records are often called in court in some cases such as road traffic accidents, medical malpractice, insurance claims • Personal documents used for research purposes require patient consent as well as personal information of the patient not disclosed 335 Proceedings the 10th students scientific research conference 1.1.4: Meaning of medical records Due to the above characteristics, medical records have important and irreplaceable meanings These basic meanings are: 1.1.4.1: practical meanings Because medical records have a direct relationship to human health, it has a great significance in the real world Some typical meanings are: • Real patient monitoring • Medical research • Medical education • For insurance, personal injury, employee compensation, a criminal case, case • For litigation • For medical audit and statistical research In addition, medical records reflect the relationship between the physician and the patient during the course of treatment is recorded in the medical record The attitudes, behaviors, and satisfaction of patients with the hospital can be assessed 1.1.4.2: Historical-Scientific Meaning Systematic records are very important and necessary materials to summarize and research scientific issues such as diseases, new treatments, new exploration methods, pathological characteristics A good medical record serves the interests of doctors as well as their patients It is very important that the treating doctor properly record the management of the patient under his or her care Thus, medical record keeping has evolved into the science Domestic and international medicine has had different stages of development and development with the aim of becoming more complete Because of that, electronic medical records were born to overcome the limitations of traditional paper medicine In the era of science-technology development such as dancers, the electronic medical birth is inevitable and obey the laws of nature and society Medical records also have a great historical significance for Vietnamese and world medicine Because, thanks to the results of the previous ones, thanks to the historical studies, medicine will not be as it is today Thanks to that history, we can know individuals, organizations have great merit in the development of our medical history as Ho Dac Di, Dang Van Ngu, Ton That Tung, 336 Proceedings the 10th students scientific research conference Therefore, it can be reassured that medical records are extremely important and that no document can be replaced 1.1.5 Difficult of medical paper: 1.1.5.1 For hospital leaders: - Incorrect information: Hospital management is dependent on information collected from functional departments, but this information is often delays, omissions, and misleading information Forms of paper reports, oral reports, meetings have many limitations on accuracy and reliability Reporting data is influenced by the sentiment and expertise of the reporter - Inadequate information: The hospital's activities are now reflected in discrete, incomplete, interlinked reports Most of the reported data coming from different parts not match the figures when compared Therefore, the hospital leadership cannot fully supervise hospital operations - Loss of assets, lack of financial transparency: Because each department manages a function of the hospital, there is no check, collate, verify immediately should occur the loss of property, loss Hospital fees, which are prominent groups of management fees, pharmaceuticals, public assets Negative: Negative situations cannot be investigated by accidental or intentional employees 1.1.5.2 For hospital staff: - Lack of human resources: Currently, Vietnam lacks human resources for health due to inadequate training Hospitals are always overloaded - Human lack of professional quality: Due to busy in overload patients, doctors lose the ability to train themselves due to lack of time, lack of books The knowledge of doctors is always old compared to The world's information situation is constantly changing - Waste of professional staff: Doctors are trained in medical specialty but must administrative work Administrative work is an unprofessional work for the doctor, which limits the effectiveness of administrative work and the loss of professional competence Reporting data always takes a lot of time and effort to the doctor 337 Proceedings the 10th students scientific research conference Figure 52: Difficult of medical paper for hospital staffs - Waste of storage and retrieval of medical data: Doctors cannot store patient records in a scientific way Most of the medical records are stored in paper, the contents of the recordings are insufficient Although medical records are stored, it is rarely exploited for scientific research - Waste of information: When examining and treating patients, doctors cannot see the medical history accurately and accurately, especially the way the chronic disease Therefore, the assessment of the condition will lead to errors There is no memory facility, no library system available to support the work The doctor cannot remember everything, so there is a need for a memory system, a library in place for reference as needed This helps to improve the value of the doctor's work, which is beneficial to the patient Para clinical data such as tests; diagnostic imaging are not stored This is the data warehouse for scientific research - Waste of time: While doing medical records, medical examination, doctors spend a lot of time writing on paper At each stage of the examination, patient information must be recorded repeatedly Patients with chronic illnesses who need multiple examinations should also record administrative details, which can take time - Harms the patient: Many doctors write hard-to-read prescriptions that make it difficult for the patient Wrong handwritten bad letters not only help save lives but also 338 Proceedings the 10th students scientific research conference can harm patients because of the wrong medication or use the wrong way Prescriptions are not contraindicated; drug interactions will also harm the patient 1.1.5.3 For patients: - Many troubles in medical examination and treatment: The cumbersome administrative procedures in patient registration make troublesome for patients The time to receive medical services is less than waiting time, loading due to administrative procedures such as registration, hospital fees, waiting for medicine Figure 53: Difficult of medical paper for patients Negative: When procedures are difficult for the patient, there is a negative relationship between the patient and the healthcare provider Victims, hooks occur in many places - Medical harm: Patients with special conditions such as allergies, pregnancy, lactation, children or special diseases should avoid using potentially harmful drugs As doctors lack information about the patient as well as lack of information about the drug, these patients are taking drugs that are contraindicated and harmful - Do not get information about your disease: Patients cannot keep their health records in a consistent, complete way to transfer to another hospital when needed Elderly patients with chronic diseases such as hypertension, diabetes or special diseases such as mental illness, kidney failure, cancer are often required to keep records in a 339 Proceedings the 10th students scientific research conference • The outpatient health insurance used to distribute drugs to health insurance holders has a close relationship with the health insurance module, only after the approval 3.3.3.1.6: Residential management module: • Hospital admittance management function: Revise the patient cover sheet The information on hospitalization, discharge, transfer, treatment results are saved to the data for the reports according to each criterion • Medical record and medical records: The doctor records medical records and hospitalizations daily in the software, equivalent to the medical records • 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 re-distribution 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: 365 Proceedings the 10th students scientific research conference Figure 70: Medicine management for a patient 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 366 Proceedings the 10th students scientific research conference 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, 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 367 Proceedings the 10th students scientific research conference 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 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 368 Proceedings the 10th students scientific research conference 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 distribution profile Electronic medical records Access privilege, at the same time Passive: cannot start the action Active: can initiate certain actions depending on the data Presentation of non-normative information Information storage is more standardized, 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 Can increase the completeness by checking additional structures when entering data The risk of lack of information is greater (less check on full completion information) Presentation of data is not flexible (only a single representation) Spend plenty of time researching financial or medical research There is no risk of technical failures Lower cost (only the initial cost is not the full cost) Flexible presentation of data across multiple "angles" to meet needs (on an individual / patient basis or as a whole) An excellent foundation for managing and directing financial and medical research The risk of technical failure and nonuse is dependent on the substance hardware / software Higher costs for installation, staff training 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 distribution profile Access privilege, at the same time 369 Proceedings the 10th students scientific research conference Passive: cannot start the action Active: can initiate certain actions depending on the data Presentation of non-normative information Information storage is more standardized, 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 (less check on full completion information) Can increase the completeness by checking additional structures when entering data Presentation of data is not flexible (only a single representation) Flexible presentation of data across multiple "angles" to meet needs (on an individual / patient basis or as a whole) An excellent foundation for managing and directing financial and medical research The risk of technical and non-technical failures depends on the quality of the hardware / software Spend plenty of time researching financial or medical research There is no risk of technical failures Lower cost (only the initial cost is not the full cost) Higher costs for installation, staff training and system management Doctors manually enter data manually There may be resistance and anxiety among doctors for entering data into the computer Difficult to maintain security and reliability (tracking and logging) Confidentiality; easy to access 3.3.2: Limitations  Technology: • Medical data is large, transmission speed is high, accurate and no interference • 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: x-ray film, digital x-ray, electrocardiogram, cardiac electrocardiogram 370 Proceedings the 10th students scientific research conference • 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 371 Proceedings the 10th students scientific research conference Chapter 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 372 Proceedings the 10th students scientific research conference Increase the application/database server ram capacity from to 16 GB • 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-AvailabilityScalability), systems that meet these three requirements are referred to as RAS (separate from Remote Access Service as remote access service) 373 Proceedings the 10th students scientific research conference 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] 374 Proceedings the 10th students scientific research conference 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 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 375 Proceedings the 10th students scientific research conference 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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