RESUMO

OBJECTIVE: To assess the completeness and accuracy of neonatal resuscitation documentation the electronic medical record (EMR) compared with a data-capture system including video. STUDY DESIGN: Retrospective observational study of 226 infants assessed for resuscitation at birth between April 2019 and October 2021 at Sharp Mary Birch Hospital, San Diego. Completeness was defined as the presence of documented resuscitative interventions in the EMR. We assessed the timing and frequency of interventions to determine the accuracy of the EMR documentation using video recordings as an objective record for comparison. Inaccuracy of EMR documentation was scored as missing (not documented), under-reported, or over-reported. RESULTS: Overall, the completeness of resuscitation interventions documented in the EMR was high (85%-100%), but the accuracy of documentation varied between 39% and 100% Modes of respiratory support were accurately captured in 96%-100% of the EMRs. Time to successful intubation (39%) and maximum fraction of inspired oxygen (47%) were the least accurately documented interventions in the EMR. Under-reporting of interventions with several events (eg, number of positive pressure ventilation events and intubation attempts) were also common errors in the EMR. CONCLUSIONS: The self-reported modes of respiratory support were accurately documented in the EMR, whereas the timing of interventions was inaccurate when compared with video recordings. The use of a video-capture system in the delivery room provided a more objective record of the timing of specific interventions during neonatal resuscitations.

RESUMO

Background: Children (aged 0-14 years) living with HIV often experience lower rates of HIV diagnosis, treatment, and viral load suppression. In Haiti, only 63% of children living with HIV know their HIV status (compared to 85% overall), 63% are on treatment (compared to 85% overall), and 48% are virally suppressed (compared to 73% overall). Electronic medical records (EMRs) can improve HIV care and patient outcomes, but these benefits are largely dependent on providers having access to quality and nonmissing data. Objective: We sought to understand the associations between EMR data missingness and interruption in antiretroviral therapy treatment by age group (pediatric vs adult). Methods: We assessed associations between patient intake record data missingness and interruption in treatment (IIT) status at 6 and 12 months post antiretroviral therapy initiation using patient-level data drawn from iSanté, the most widely used EMR in Haiti. Missingness was assessed for tuberculosis diagnosis, World Health Organization HIV stage, and weight using a composite score indicator (ie, the number of indicators of interest missing). Risk ratios were estimated using marginal parameters from multilevel modified Poisson models with robust error variances and random intercepts for the facility to account for clustering. Results: Data were drawn from 50 facilities and comprised 31,457 patient records from people living with HIV, of which 1306 (4.2%) were pediatric cases. Pediatric patients were more likely than adult patients to experience IIT (n=431, 33% vs n=7477, 23.4% at 6 months; P<.001). Additionally, pediatric patient records had higher data missingness, with 581 (44.5%) pediatric records missing at least 1 indicator of interest, compared to 7812 (25.9%) adult records (P<.001). Among pediatric patients, each additional indicator missing was associated with a 1.34 times greater likelihood of experiencing IIT at 6 months (95% CI 1.08-1.66; P=.008) and 1.24 times greater likelihood of experiencing IIT at 12 months (95% CI 1.05-1.46; P=.01). These relationships were not statistically significant for adult patients. Compared to pediatric patients with 0 missing indicators, pediatric patients with 1, 2, or 3 missing indicators were 1.59 (95% CI 1.26-2.01; P<.001), 1.74 (95% CI 1.02-2.97; P=.04), and 2.25 (95% CI 1.43-3.56; P=.001) times more likely to experience IIT at 6 months, respectively. Among adult patients, compared to patients with 0 indicators missing, having all 3 indicators missing was associated with being 1.32 times more likely to experience IIT at 6 months (95% CI 1.03-1.70; P=.03), while there was no association with IIT status for other levels of missingness. Conclusions: These findings suggest that both EMR data quality and quality of care are lower for children living with HIV in Haiti. This underscores the need for further research into the mechanisms by which EMR data quality impacts the quality of care and patient outcomes among this population. Efforts to improve both EMR data quality and quality of care should consider prioritizing pediatric patients.

RESUMO

La gestión de la información de salud del paciente, así como de los diferentes servicios que se brindan en los centros de atención de salud, constituyen elementos cruciales para prestar un servicio de salud de buena calidad. El Sistema de Información Hospitalaria XAVIA HIS, constituye una solución integral para la gestión médica de hospitales y centros de salud. En el módulo de Consulta externa se gestiona la información referente a la atención a pacientes ambulatorios en diferentes especialidades. El objetivo del presente trabajo es describir las principales funcionalidades y especialidades médicas incluidas en el módulo Consulta externa del sistema XAVIA HIS. El desarrollo estuvo guiado por la metodología de desarrollo Proceso Ágil Unificado. variante UCI y fueron empleadas las tecnologías, herramientas y lenguajes que forman parte de la arquitectura del sistema definida por el Centro de Informática Médica, entre las cuales se pueden mencionar: Java Enterprise Edition 6 como plataforma de programación para el desarrollo y la ejecución del sistema, como sistema gestor de base de datos se empleó PostgreSQL 10, como herramienta de modelado Visual Paradigm para UML, la notación BPMN 2.0 (Business Process Management Notation) y el Lenguaje Unificado de Modelado (UML) y el estándar HL7 CDA® (Clinical Document Architecture) para homogeneizar la arquitectura de los documentos clínicos. El desarrollo de este módulo refuerza la base de conocimientos necesaria para la toma de decisiones clínicas y administrativas, mejora el acceso a la información y la calidad de la asistencia a los pacientes.

The patient's health information management, as well as different services provided in health care centers, constitutes crucial elements to provide a good quality health service. The Hospital Information System XAVIA HIS establishes a comprehensive solution for hospitals and health centers medical management. The Outpatient module manages the information regarding outpatient care in different specialties. This paper aims to describe the main functionalities and medical specialties included in the Outpatient module of the XAVIA HIS system. The development was guided by the AUP development methodology (an UCI variant), and to achieve it, the technologies, tools and languages used are part of the system architecture defined by the CESIM and mentioned as follow: Java Enterprise Edition 6 platform as the Runtime Environment, PostgreSQL 10 as the database management system, Visual Paradigm as modeling tool for UML, the BPMN 2.0 notation (Business Process Management Notation), the Unified Modeling Language (UML) and the HL7 CDA® (Clinical Document Architecture) standard to standardize the architecture of clinical documents. This module development reinforces the knowledge base necessary for clinical and administrative decision-making, improves access to information and patients' care quality.

RESUMO

Electronic Health Records (EHR) are critical tools for advancing digital health worldwide. In Brazil, EHR development must follow specific standards, laws, and guidelines that contribute to implementing beneficial resources for population health monitoring. This paper presents an audit of the main approaches used for EHR development in Brazil, thus highlighting prospects, challenges, and existing gaps in the field. We applied a systematic review protocol to search for articles published from 2011 to 2021 in seven databases (Science Direct, Web of Science, PubMed, Springer, IEEE Xplore, ACM Digital Library, and SciELO). Subsequently, we analyzed 14 articles that met the inclusion and quality criteria and answered our research questions. According to this analysis, 78.58% (11) of the articles state that interoperability between systems is essential for improving patient care. Moreover, many resources are being designed and deployed to achieve this communication between EHRs and other healthcare systems in the Brazilian landscape. Besides interoperability, the articles report other considerable elements: (i) the need for increased security with the deployment of permission resources for viewing patient data, (ii) the absence of accurate data for testing EHRs, and (iii) the relevance of defining a methodology for EHR development. Our review provides an overview of EHR development in Brazil and discusses current gaps, innovative approaches, and technological solutions that could potentially address the related challenges. Lastly, our study also addresses primary elements that could contribute to relevant components of EHR development in the context of Brazil's public health system. Systematic review registration: PROSPERO, identifier CRD42021233219, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233219.

Assuntos

RESUMO

La elaboración del expediente clínico es una actividad rutinaria dentro del consultorio dental, éste es la materialización del acto médico, a tra- vés del cual se registra el estado de salud inicial del paciente, así como toda la información relativa al tratamiento recibido. Desde hace algunos años comenzó a promocionarse el expediente clínico electrónico como una herramienta alternativa y novedosa para elaborar este importante documento; sin embargo, la implementación de esta herramienta electrónica no ha podido lograrse en México, dada la gran cantidad de dudas que los odontólogos tienen respecto al conjunto de leyes y normas que regulan al expediente clínico, lo cual genera renuencia por parte de los odontólogos para utilizar esta modalidad de expediente dentro de su consulta diaria. El objetivo del presente artículo es realizar una revisión de la literatura, así como de las leyes y normas vigentes que regulan el expediente clínico en México para esclarecer así la viabilidad de implementarlo dentro del consultorio dental

The preparation of the electronic medical record is a routine activity in the dental office, this is the materialization of the medical act, through which the initial health status of the patient is recorded, as well as all the information related to the received treatment. A few years ago, the electronic clinical record began to be promoted as a novel alternative tool to prepare this important document, however, the implementation of this electronic tool has not been achieved in Mexico, given the large number of doubts that dentists have regarding the set of laws thar regulate the clinical record, which generates reluctance on the part of dentists to use this record modality within their daily consultation. The aim of this article is to carry out a review of the literature, as well as the current laws that regulate the clinical record in Mexico, in order to clarify the feasibility of implementing it within the dental office

Assuntos

RESUMO

Resumen: Objetivo: Evaluar los factores relacionados con el uso del Expediente Clínico Electrónico (ECE) desde la percepción de los usuarios médicos y enfermeras de los servicios de salud de un hospital de 2do nivel en Morelos, México. Material y métodos: Se realizó el análisis cualitativo de 22 entrevistas semiestructuradas a personal médico, enfermeras, directivo y administrativo de un hospital de 2do nivel en Morelos, México, tomando como referencia de análisis las dimensiones de normatividad, operatividad y capacitación en la implementación del ECE. Resultados: Se identificó un número insuficiente de computadoras y personal capacitado para operar el ECE. Cuando se logra operar el expediente éste es lento o presenta fallas sistemáticas frecuentes debido a las redes de navegación dependen del navegador central que brinda soporte estatal a la plataforma del ECE sin una resolución pronta cuando hay fallas, las unidades hospitalarias trabajan 24 horas y a nivel central las operaciones del ECE tienen horarios de lunes a viernes de 8 horas. Esto incrementa la resistencia a adoptar el expediente como herramienta de trabajo. La organización colabora a la resistencia al no proporcionar un soporte técnico suficiente y permanente para afrontar las fallas de operatividad del ECE. Los usuarios consideran que el expediente es seguro y confiable, lo cual incrementaría la posibilidad de uso del ECE. Conclusiones: La falta de recursos e ineficiencias en la operación del ECE colaboran a una baja y lenta adopción del expediente; así como la resistencia a utilizarlo. La organización colabora a aumentar la resistencia si la capacitación no es eficiente. Falta le da soporte continuo y suficiente en la infraestructura técnica y recurso humano. A pesar la limitada e ineficiente adopción del ECE se identificaron áreas y personal donde se presenta una mayor utilización (hospitalización y personal médico). Éstas podrían ser las experiencias de aprendizaje positivo que pueden utilizarse para instruir a toda la organización

Abstract: Objective: To evaluate the factors related to the use of the Electronic Medical Record (ECE) from the perception of medical users of health services Morelos, Mexico. Material and methods: The qualitative analysis of 22 semi-structured interviews with medical personnel, nurses, managers and administrators of a 2nd level hospital in Morelos, Mexico was carried out, taking as a reference for analysis the dimensions of regulations, operability and training in the implementation of the ECE. Results: An insufficient number of computers and trained personnel were identified to operate the ECE. When it is possible to operate the file, it is slow or presents frequent systematic failures due to the navigation networks, they depend on the central browser that provides state support to the ECE platform without a prompt resolution when there are failures, the hospital units work 24 hours and centrally. ECE operations have 8-hour hours from Monday to Friday. This increases resistance to adopting the file as a working tool. The organization contributes to the resistance by not providing sufficient and permanent technical support to face the operational failures of the ECE. Users consider that the file is safe and reliable, which would increase the possibility of using the ECE. Conclusions: The lack of resources and inefficiencies in the operation of the ECE contribute to a low and slow adoption of the file; as well as the resistance to use it. The organization helps increase resistance if training is not efficient. Lack gives you continuous and sufficient support in the technical infrastructure and human resources. Despite the limited and inefficient adoption of ECE, areas and personnel were identified where there is greater use (hospitalization and medical personnel). These could be positive learning experiences that can be used to educate the entire organization

RESUMO

BACKGROUND: Determining the clinical effort associated with preparing for revision total hip and knee arthroplasty is necessary to maintain the appropriate work relative value unit rating. We have investigated the work done by the orthopedic surgical team in the days and weeks prior to revision hip and knee arthroplasty using a count of time by team members in the electronic medical record (EMR). METHODS: EMR audit logs were generated, and preoperative work (POW) was calculated for members of the surgical team for 200 sequential revision cases. Independent samples t-tests were conducted to compare total POW for procedure, age, gender, insurance, and health literacy; significance threshold was set at P = .05. RESULTS: POW was 97.7 minutes (standard deviation [SD] 53.1). Surgeon POW accounted for 10.5 minutes (SD 9.3), nurses for 29.9 minutes (SD 34.2), mid-level providers for 22.1 minutes (SD 17.0), and office technicians for 34.1 minutes (SD 35.2). There was no difference in total POW based on procedure (hip vs knee), age, gender, insurance type, or health literacy. CONCLUSION: Revision arthroplasty requires substantial preoperative preparation from the surgical team. Most of this is by nurses, mid-level providers, and office staff. This does not seem to be different for hip or knee revisions or by age and gender. EMR audit logs capture the bare minimum POW required to prepare a patient for revision arthroplasty.

Assuntos

RESUMO

Resumo Como parte do estudo de avaliabilidade da avaliação da implementação do Prontuário Eletrônico do Paciente (PEP), o objetivo desta Revisão Sistemática (RS) foi identificar os domínios de avaliação a serem abordados. Esta RS, alinhada com o Cochrane Handbook for Systematic Reviews of Interventions e o Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) englobou artigos publicados de 2006 até 2019. Realizou-se a busca nas bases de dados eletrônicas SciELO, Oásis IBICT, BVS Regional e Scopus. A busca retornou 1.178 artigos, sendo 42 que atenderam aos critérios de inclusão. A maioria dos estudos utilizaram métodos qualitativos para análises. As publicações ocorreram entre 2006 e 2019, tendo sua concentração em 2017 com 9 (21%) artigos publicados. Não foram identificados estudos publicados em 2008 e 2009. Somente 10 estudos incluíam descrição, análises ou resultados relacionados aos domínios de implementação. Os principais domínios em que o PEP foi problematizado foram: subutilização; resistência dos profissionais ao seu uso; ênfase na usabilidade; e o PEP como repositório de informações. Apesar da inclusão de todos os estudos que contemplaram os princípios e diretrizes da Política Nacional de Humanização (PNH), eles ainda são incipientes.

Abstract As part of the evaluability study of the implementation of the Electronic Patient Record (EPR) evaluation, the aim of this Systematic Review (SR) was to identify the evaluation domains to be addressed. This SR, aligned with the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) encompassed articles published from 2006 to 2019. The search was carried out in the electronic databases SciELO, Oasis IBICT, BVS Regional and Scopus. The search resulted in 1,178 articles, 42 of which met the inclusion criteria. Most studies used qualitative methods for the analyses. The publications took place between 2006 and 2019, with a concentration in 2017 with 9 (21%) articles published in that year. No studies were published in 2008 and 2009. Only 10 studies included the description, analysis or results related to the domains of implementation. The main domains in which the EPR was problematized were: underutilization; professionals' resistance to its use; emphasis on usability; and EPR as an information source. Despite the inclusion of all studies that covered the principles and guidelines of the National Humanization Policy (NHP), they are still incipient.

Assuntos

RESUMO

El Sistema de Información Hospitalaria XAVIA HIS desarrollado por el Centro de Informática Médica (CESIM) está compuesto por módulos que aseguran la informatización de los procesos de las áreas de la institución hospitalaria. En la actualidad la gestión de los principales medios de diagnóstico se realiza de forma dispersa en diferentes módulos o sistemas. En este trabajo se presenta el módulo de Medios de Diagnóstico, desarrollo que permite la gestión de informes de solicitudes y resultados de forma configurable, así como la planificación de horarios y gestión de citas. Se analizó el proceso de negocio asociado a la gestión de información de medios de diagnóstico, se realizó un estudio de sistemas existentes con propósitos similares y se evaluaron tecnologías para su implementación. Se utilizó AUP-UCI como metodología de desarrollo, Java como lenguaje de programación y otras tecnologías libres y multiplataforma. El patrón arquitectónico implementado fue modelo-vista-controlador. El módulo de Medios de Diagnóstico del sistema XAVIA HIS, permite el soporte de los procesos de atención al paciente y la integración de la información sobre los medios de diagnóstico, además fomenta un aumento en la calidad del servicio. El módulo facilita la configuración de aspectos de solicitud e informe de las pruebas diagnósticas y la planificación de horarios y citas(AU)

Hospital Information System XAVIA HIS developed by the Medical Informatics Center (CESIM) is made up of modules that ensure the computerization of hospital institution areas processes. Currently, the management of the main diagnostic means is realized in a dispersed way in different modules or systems. This paper presents the Diagnostic Means module, development that allows the requests and results reports management in a configurable way, as well as the schedules planning and appointments management. The business process associated with the diagnostic means information management was analyzed, an existing systems study with similar purposes was carried out, and technologies for their implementation were evaluated. AUP-UCI were used as development methodology, Java as programming language and other free and multiplatform technologies. The architectural pattern implemented was model-view-controller. The XAVIA HIS system Diagnostic Means module, allows the patient care processes support and integration of information regarding diagnostic means, also encourages an increase in the service quality. The module facilitates the request and report aspects configuration of the diagnostic tests and the schedules and appointments planning(AU)

Assuntos

RESUMO

La digitalización de la historia clínica, documento indispensable en la atención de salud y que posee carácter legal, es uno de los focos de atención en la e-Salud. El sistema XAVIA HIS compuesto por módulos que informatizan los procesos e interconectan las diferentes áreas de una institución hospitalaria, posee como atributo fundamental, una historia clínica electrónica única por paciente. Esta se compone por documentos basados en el estándar HL7-CDA. Sin embargo, el sistema XAVIA HIS presenta algunas limitantes en la interacción con otras aplicaciones que gestionen la información de salud. En el trabajo se presentan las modificaciones a realizar al Sistema de Información Hospitalaria XAVIA HIS para mejorar la capacidad de gestión de las historias clínicas electrónicas del sistema. Se realizó un análisis de la literatura disponible sobre la gestión de las HCE y se evaluó el mecanismo que emplean sistemas homólogos nacionales e internacionales. Para guiar el desarrollo de la propuesta se empleó la metodología AUP-UCI; UML se empleó para el modelado de los artefactos de ingeniería y BPMN como lenguaje de notación para los procesos de negocio. Las modificaciones que se presentan, le permitirán al sistema XAVIA HIS interactuar con sistemas externos que generen documentos HL7-CDA. Adicionalmente, se añaden funcionalidades para mejorar la impresión de documentos clínicos que se exportan, así como la generación de resúmenes de la historia clínica(AU)

One of the e-Health approaches is the digitalization of the medical record, an essential document in health care and with a legal character. The XAVIA HIS system, made up of modules to manage the processes and interconnect the different areas of a hospital institution, has as a fundamental attribute, a unique electronic medical record per patient. It is made up of documents based on the HL7-CDA standard. However, the XAVIA HIS system presents some limitations to interaction with other applications also managing health information. This paper presents the new features and changes to be made to the Hospital Information System XAVIA HIS to improve the electronic medical records management of the mentioned system. An analysis of the available literature on EHR management was carried out and the mechanism used by national and international counterpart systems was evaluated. To guide the development of the proposal, the AUP-UCI methodology was used; UML was used for modeling the engineering artifacts and BPMN as a notation language for business processes. The modifications that are presented will allow the XAVIA HIS system to interact with external systems which also generate HL7-CDA documents. Additionally, functionalities are added to improve the printing of clinical documents that are exported, as well as the generation of summaries of the medical record(AU)

Assuntos