Patient Records and Usability - Uppsala .Informationsteknologi Institutionen f¶r informationsteknologi

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  • Patient Records and Usability

    Rebecka Janols 2010-11-05

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    Institutionen fr informationsteknologi | www.it.uu.se

    Last lecture The patients way through the health care is

    called care process. Medical records is a systematic documentation

    of a patient's medical history and care. Physician, nurse, psychologist, physiotherapist,

    welfare officer are legally required to document. The medical record can be time,-problem,-

    source oriented. Patient Data Act : improve patient security and

    protect sensitive data.

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    Institutionen fr informationsteknologi | www.it.uu.se

    Problems with EPR 1. User interface 2. Safety 3. Terminology 4. Communication

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    Institutionen fr informationsteknologi | www.it.uu.se

    Problem 1: User interface Overview of information Different type of information should be

    presented: text, numbers, images, voice Different ways for data input:

    Free text Structured Voice

  • Cosmic

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    Institutionen fr informationsteknologi | www.it.uu.se

  • TakeCare

  • TakeCare to do

  • Take Care to do- at this unit

  • TakeCare to do with this patient

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    Institutionen fr informationsteknologi | www.it.uu.se

    The patient card

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    Institutionen fr informationsteknologi | www.it.uu.se

    My master thesis

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    Institutionen fr informationsteknologi | www.it.uu.se

    Health issue patient overview

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    Institutionen fr informationsteknologi | www.it.uu.se

    Health issue overview

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    Institutionen fr informationsteknologi | www.it.uu.se

    Problem 2: Safety Secrecy Accessibility Correctness Traceability

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    Institutionen fr informationsteknologi | www.it.uu.se

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    Institutionen fr informationsteknologi | www.it.uu.se

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    Institutionen fr informationsteknologi | www.it.uu.se

    Problem 3: Terminology Confusion about the meaning of words.

    Different words for the same thing Same word for different things Free text

    Different terminology between different roles.

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    Institutionen fr informationsteknologi | www.it.uu.se

    Anamnesis and Status Anamnesis: Physician: patient history in health care Nurse: information about the patient

    before the patient comes to the care

    Status: Physician: objective findings Nurse: how the patient feels today

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    Institutionen fr informationsteknologi | www.it.uu.se

    Care process vs. reality Care process is a simplified model of the

    reality Reality is more complex The systems support the care process not

    the reality.

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    Institutionen fr informationsteknologi | www.it.uu.se

    Coding and Classification The computer understand Same in different countries Easier to make statistics The structure and level of details of the

    classification system depend on its purpose. Many different coding and classification. ICD 10: Diseases and Related Health Problems ICF: International Classification of Functioning,

    Disability and Health SNOMED-CT: Complete medical terminology

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    Institutionen fr informationsteknologi | www.it.uu.se

    Problem 4: Communication Information in many systems

    Different architecture Different information structure

    Integration & interoperability Technical interoperability Semantic interoperability

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    Institutionen fr informationsteknologi | www.it.uu.se

    Communication 36 different kind of systems at

    Akademiska Hospital National quality register, 71 in Sweden.

    (ex. Different kind of cancers, diabetes, Asthma and trauma)

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    Institutionen fr informationsteknologi | www.it.uu.se

    Can you think of any other problems?

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    Institutionen fr informationsteknologi | www.it.uu.se

    Trends. NP National Patient Overview European Patient Overview Medical account so the patient can get

    access to her own medical record.

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    Institutionen fr informationsteknologi | www.it.uu.se

    Summary The problem with the computer based medical

    records are: User interface Safety Terminology Communication

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