Electronic medical record of the patient

An electronic medical card of an outpatient patient in the near future can greatly facilitate the work of the staff of polyclinics. Paper options will gradually begin to go into oblivion.

About what an electronic medical record is

It represents a promising area in the development of outpatient care. The fact is that from the abundance of paper maps and their shortcomings suffer both patients, and almost all employees of polyclinics. An electronic medical record is created for the convenience of the former and facilitates the work of the second. In addition, it greatly simplifies the work of statistics and the organizational and methodical department of any treatment and prevention center.

At the same time, the patient's electronic medical record can include all the information that is available in the paper version.

How it works?

Currently, all medical and preventive institutions are trying to maximize computerization. In particular, a quality electronic medical map has already been developed. It makes it possible to greatly simplify the work of clinic staff and the lives of patients themselves.

The medical card in electronic form is arranged quite simply. It is enclosed in an electronic card file, which is part of a single program of an automated workplace of a specialist. In order to gain access to a particular card, a doctor or a nurse, it is enough just to type the patient's last name, first name and patronymic in the search field. In the event that the program issues several titles (when there are several patients with the same name), the user is already guided by the year of birth and the address of the person's residence. In the map, if it has already been filled, you can find a large amount of information relating to this particular patient. At the same time, there it is possible to quickly trace the dynamics of visits by a person to a doctor. Naturally, here it is possible to get acquainted with all the diagnoses that were exhibited to the patient.

It is worth noting that even the most modern electronic medical card of an outpatient patient would not make sense if it were not part of the program that unites all the computers of medical specialists working in a medical and preventive institution. As a result, when the surgeon fills out the diary in digital form, the therapist, gynecologist and any other doctor of the polyclinic are able to see the final conclusion in real time. That is, the program has a single base.

What was the purpose of creating an electronic map?

It became a necessity as a result of the general computerization of society's life. The creation of an electronic medical map has been planned for a long time. Everyone is already very tired of working with paper documents, which have a huge number of shortcomings. In addition, a single electronic medical card can significantly simplify the activities of hospitals, because they now have the opportunity to request information about the patient who came to them for treatment, in digital form. This greatly simplifies the work, because doctors do not need to find out what exactly a person was sick for their lives.

Advantages of electronic card in front of paper

It should be noted that she really has a large number of pluses. First of all, such a card will not be lost and will not be taken away by the patient home. As a result, all information is stored in the clinic.

Another advantage is that there is no need to search for a card and then transmit it to another doctor. All the necessary information is already on his computer.

Naturally, the big advantage of electronic medical cards is the lack of the need to permanently paste additional sheets, advisory opinions, and also forms with the results of analyzes. All information of this type is entered in special sections of the program, which gives all the necessary data for the first request from the doctor.

The electronic medical card also positively positively characterizes itself for the reason that it allows several specialists of the polyclinic to get acquainted with their content. At the same time, they are able not only to read it, but also to fill it. As a result, the activity of medical personnel is significantly optimized.

Disadvantages of electronic cards

Like any invention, it also has some drawbacks. First of all, it should be noted that in the event of a power outage, the electronic medical record will be completely inaccessible for viewing.

Another drawback is the fact that valuable information can be stolen by hackers. In addition, an electronic medical record can be completely destroyed in the event that something happens to the computer on which the databases are located.

A noticeable minus of such documentation is also the need for staff training to work with it. If young doctors and medical sisters quickly master new technologies, especially those connected with computers, then older employees experience serious difficulties in using any innovations, especially those dealing with computing.

The main problems of universal introduction of electronic maps

In addition to difficulties with staff training, there are others. This is primarily about the need to computerize the workplaces of all doctors and a fair portion of nurses. To do this, the management of the treatment and prophylactic institution will have to spend a considerable amount of money. Let not as fast as we would like, but this difficulty is solved.

A much greater problem after the electronic medical card will be introduced legally in the form of the main document for medical and preventive institutions will be the transfer of information from paper to electronic media. While it is not clear to the end who will do this. The doctor does not have enough time to maintain an electronic medical record, and, of course, he will not be engaged in the digitization of documentation. As for the nurses and, especially, the employees of the registry, they simply do not have the appropriate knowledge to correctly and qualitatively introduce full-fledged information. Naturally, no one will hire additional employees. Most likely, the problem will be solved by the parallel management of both electronic and paper documentation for several years. At the same time, this approach will again create great problems for doctors and nurses in the field. So before creating an electronic medical record, you have to solve this problem.

Prospects for the development of the industry

An electronic medical map is created in such a way that in the future, fully optimize the activities of medical and preventive institutions. In the future, it can get such a serious development that the registry will not be needed. This will release significant human resources. In the future, this will help to increase the staff of pre-hospital rooms. Advantages from their introduction have already been felt by patients, doctors with medical sisters, and even the administration.

There is one more promising direction, along which the electronic medical map will develop. How to get data from colleagues who work not only in one medical-preventive institution, but also in all medical centers of the country? Of course, with the help of a universal unified electronic medical record. That is, in the long term a unified database will be created that will unite all medical institutions of the country into the network. As a result, information about the patient will not be lost, and the doctor, seeing the person for the first time and being thousands of kilometers from his attending physician, will be able to learn the full medical information about him in a matter of minutes. In addition, this circumstance will help to exclude and some fraud with different kinds of medical documents.

Protection against breakage of equipment

Currently, a serious problem remains the possibility of a computer failure, on which there is a database with a full electronic card file of a clinic. A good solution is to periodically create backup copies of a similar database with their placement on different computers. In the event that one electronic computing device is broken and can not be restored, another one will be launched instead of it, and no serious difficulties in the work of the personnel with the software will arise.

Another solution may be to place a backup copy of the database in various online storages, but such actions will greatly facilitate the process of obtaining information about patients by hackers, and this is unacceptable.

What is the benefit for the patient?

In creating electronic medical records, there are many positive points for the patient himself. First of all, he can be sure that not a single piece of paper will disappear from his documentation. In addition, he will not have to wait for a long time, while the staff of the registry will deliver his medical card. In the near future everything will be much easier. The patient will only need to make an appointment with the doctor. Entering the clinic, he will need to produce a document such as a paper or electronic health insurance card. After that, he will immediately be able to go to the specialist in consultation who needs it.

Another advantage for the patient is the fact that information about which doctor he was at the reception, what diagnoses he was given, and the results of his analyzes would be inaccessible to junior medical personnel. The matter is that now out-patient medical cards in the majority settle down in registry. Registrars work there. If desired, they have the opportunity to view any map both for their own interest, and for someone else's request. In the future, they will not have such an opportunity.

When will the project be implemented?

In fact, when the patient's single electronic medical record was still in the development stage, its full-scale introduction, which implies a complete stoppage of the turnover of paper documentation in clinics, was already predetermined. Unfortunately, this promising project constantly encounters new obstacles of various kinds. Initially, the main problem was the material provision of polyclinics. In the future it was necessary to train the staff. Now the big obstacle is to ensure fast and uninterrupted operation of the program. In the near future, this problem will also be eliminated, and then there will be one, but the most serious obstacle - the digitization of paper medical records.

Economic bonuses

Despite the fact that the introduction of electronic documents into circulation requires considerable expenditure in the first stages, then it will help to save much more money. The point is that every medical-prophylactic institution spends huge sums on purchasing various paper products. With the introduction of a fully electronic system, of course, spending on energy will increase, but still the savings will be significant.

Uniform Rules

Now certain measures are being taken to systematize activities in the field of computerization of various medical centers. The fact is that at the present time there is not one version of electronic cards, but several. They are developed both by private organizations, and on the basis of medical universities. By order of the Ministry of Health, a program of an automated workplace for physicians of different profiles was also created. As a result, it is now recommended for use in treatment and prevention centers. This is necessary in order to further enable the integration of all medical institutions into a single network. As a result, keeping an electronic medical record of absolutely any person living in the country will become available for every doctor to whom he came to receive.