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Minimum Data Set for Medical Tourism Electronic Health Records
Background
Health care providers have gathered data and individual information from people who use services. Data describes the size of basic facts.
Documentation of the experiences in other cases should be sure to pay attention. On the other hand, to create technological infrastructure such as internal network (Organizational Intranet), experience electronic documentation system designed to prevent bureaucracy, is holding formal and informal conferences, database design and using high technology as the important day for move towards becoming knowledge based organization.
In health care data is stored in the patient’s health records. Numeric data elements in the patient’s medical records and other health care service providers to compare the composition and is interpreted according to records. For example, the test results with medical observation, description about the patient’s clinical information to form a diagnosis or when the patient is affected by any hazard agents so Combined Clinicians by the data and information for diagnosis, treatment plan development, impact assessment and care provided to determine the prognosis of patients.
Medical Records for more than one patient can be extracted from health records as a continuous data are combined. The continuous data are stored in a database and can be using to develop information about patients. For example, a database can include data that all patients with acute myocardial infarction are a specific time period. This data can consistently identify common characteristics that can predict disease course or supply the information that can help to provide the best method of treatment to use.
Electronic health record is a power change to organize, store and manage health data for creating a system between different health care providers to coordinate a safe, secure and effective methods for health care provider.
This record constitutes the heart of e-Health that it ensures successful implementation of public health programs as one component of achieving human development.
About 25 years ago, john kemeny said in Dartmouth College: the knowledge of computer in medicine in all fields will be necessary such as reading and writing. Therefore, the use of information technology in medical science to flexibility and overcome the rapid changes in business environment is necessary and inevitable. On the other hand, implementation of IT projects has been successful in most cases, lack of attention to factors such as technical factors, human, economic and administrative failures or stops them and bearing the cost will be enormous.
Advantages of Electronic Health Record
Each care center needs data that may be common for all care centers, it has given that a specific type of special care essential, and unique data for individual care is necessary.
A. Electronic health record with five fundamental roles:
1. It shows the history of patient health care.
2. Appropriate way to communicate and care planning for individual health care professionals provide.
3. as a legal document describing the health care provide is used.
4. It uses as a clinical information and health services source in research and evaluation of event.
5. Could be using as a great source of training health care professionals.
B. Electronic health record system functions
1. Create unique record for each patient
2. Create communication between the identifying information keys (e.g., system ID and record number) with patient records.
3. Analysis of demographic information about patients
4. Ability to data entry pertaining to non-pharmacologic order for patients including antagonism and contradictory of drug, complementary medicines including: vitamins, medicinal plants and so on.
5. Ability to separate the drug from a list of common drugs (e.g. that disabled, and failure to medical error documentation) and because of this practice to document.
6. Save a list of medications, and other factors than the patients allergic or other reactions are warning.
7. Ability to update patient history by the analysis, adds, move, or disabling the patient history items.
8. Create templates for data entry to computer
9. Storage the process notification from the early stages towards the final
10. Ability to get the height and weight charts based on time
12. Ability to register without re-entering medication order by initial data entry from previous data (template for reuse)
13. Ability associated with related diagnosis
14. Ability to make diagnostic tests order, including laboratory tests and X-ray exposes.
15. Analysis and display of static problems
16. Display the normal and abnormal results based on data from main data source
17. Display non-numerical test results in text data form.
18. Documents might place within the system or through links to external resources provided.
19. Ability to create rules for managing of diseases and preventing services based on clinical data.
20. Ability to determine and allocate tasks to complete
21. Ability to documenting the oral communications and telephone orders for patient
22. Ability to order-management by multi-user pertaining to electronic health record orders in onetime.
C. Strengths of electronic health records
1. Improve the quality of clinical care, leading to reduced costs of patient’s care.
2. Integrate whole the presented material
3. Create a complete view of patient health status
4. Reduce data errors
5. Create full patient’s monitoring
6. Applying the Standards of health information
Thus, organizations such as clinics, outpatient service providers and administrative systems to support electronic health records, and establish to management systems executive with unique performance. Using appropriate information systems and databases to support medical information processing system to complete research Information systems following the compatibility with clinical research, to create interaction and optimal management conducted through health assessment based on rational information processing system[1] that is carried out.
Technologies in health care by electronic health records form has considered as one of the most important and most urgent to improve the quality of health care. The research has shown that the only way to integrate the information and represent patients’ status and dynamic resource about health care but also lead to access to information and clinical records. Electronic communications – comprehensive training and management and community health is finally improving by setting standards, determining needs, prepare the organization, and features a series of evaluating system including continuous flexibility assessment.
Gains from ICT have considered as normal phenomenon in different aspects of human’s life in recent years. Although in business and trade has improved but still many needs of today have left and any response to them. According to problem’s variety and reasons of them, managers are concerned, disable to decision making to has confused in many organizations, and involved with e-health and lack of success in achieving appropriate national implementation plan. Is quite evident that the issue in many countries sometimes-exaggerated claims of the world and a lot of confusion but it has introduced in the field of e-Health that is a global problem.
From the above listed comes till 2007 most developed countries build any operation of electronic health records and the action has been taken seriously, though all followed a strategy of cost-efficient and are the only two countries that pioneered are Canada and New Zealand as examples of successful implementation of electronic health records are made. (Accenture 2007)
Electronic health records are capable documents that can be stored, processed or transferred information through the application of computer technology. Information in electronic health records can be use by physician far from their patients simultaneously. of course this usage would achieve by proper equipment, information and communication technology.
According Reviews of American Health Information Management Association, Electronic health record standards have divided into four broad categories: lexicon, structure-content, exchange messages and health care confidence.
Functions of electronic health records in the profession of health have related to its content, this information have included demographic and clinical information.
Demographic data means information such as patient’s full name, address, telephone number (home, work and mobile), date of birth, age, file number, marital status, sex, ethnicity, race, place of birth, name and address of nearest relative patient ( spouse, parent), name and address to contact the families in emergency, patient social security number, occupation, name and work address, name and information for referring patients to pharmacies and all information related to patient insurance status (insurance type, name and address).
Clinical information, are documentations that related to services and treatment that include: patient’s medical history and examination starts, all diagnostic tests and notes that health care providers who participate in treatment must have been completed.
Considering the importance and necessity of proper and efficient use of communication and information technology in health systems, and the past experience in this field; today
The nature of these activities between the authorities and the major managers has been confirmed the need to coordinated and comprehensive all of the facts of technology and relying on the problem solving. It must consider the appropriate and equitable opportunities for all scholars and researchers to participate in the country to create products and attract the necessary cooperation. In addition, public and private sectors to problems barriers through coordination with related sectors to absorb and implement information technology in health-based efforts has done.
Incentive plans are comprehensive integrated health system in the cloud of a national network (integration) has been.
Identified barriers such as data, information, infrastructure and data exchange standards and codes process and vocabulary list of these systems is important. Due to the challenges and complexities of electronic health records, creating the system requiring targeted strategies, because of the changes will create a way doing that requires consistency and compliance with clinical process by electronic health records. Therefore effective and efficient systems for electronic health records need to coordination with different groups, including providers, users, designers and professionals of health information management for implementing of electronic health records.
General steps to implementation of Electronic Health Records
The first step is upgrading, improvement and re-engineering current processes. The second step is deletion of resistance against using the computer system in health care. the users have essential role in the design, implementation and application of these systems, they should have involved in these activities from beginning therefore reasonable that users before using on the benefits and how to use these systems must receive the necessary training. Most basic and last point in building these systems is converge and create harmony between the standardization organizations and coordination for participation and cooperation of all interested groups and sub-organizations.
Considering the numerous of applications for information technology in healthcare service providers centers, using of this technology can optimize the costs and availability of services, and finally occur the better use and development of applications in the healthcare. So healthcare would have reformed and contributed. While the use of information technology in different industries have made significant progress but using health sector has been delayed. Therefore, the capabilities of these systems in reducing costs, (51% in the cost of medical transcription and 65% cost recovery and archive medical records and improve the quality of care that a major challenge the industry today are needed with the development and integration existing computer systems for using the data standards and training of health professionals by using appropriate medical records for these systems that would have been providing.
E-health systems in providing health services in the fields of science and technology that has been growing in the world. In fact, e-Health is a new word to describe the need to use a combination of electronic information and communication technology in the field of health and treatment that needs to continuously seek to provide the first of every society and to remove barriers to use health products to have every day more and more important to provide it, including electronic patient records, Tele Medicine, evidence-based medicine, provide informing the citizens, to inform professionals, consulting and virtual medical teams could have named.
The study, to achieve the boundaries to integration of health systems designed minimum dataset required for electronic health records clinical and Financial infrastructure, patients have been followed by the aim of seeking to identify a minimum data set.
This study trying to find a precise definition of the minimum data set has required in Electronic medical records for admitted patients in selected countries
Definition
- Electronic health record: Collecting electronic information that a person’s entire life by health care providers and approved and registered on the site distribution is different. Information aimed at supporting ongoing efficiently care, are organized under the control of customer records and transferred to a secure and are kept.
- Minimum data set: the original set of data elements by the National Health Department for collecting and reporting required at the national level has been agreed.
Methods
In this comparative cross-sectional study, the reviewed content including: print and electronic documents related to electronic health records in selected countries (America, England and New Zealand) because of their succeeds in training of information management professionals and leading health services synchronized by Information technology, system architecture and structure design, also improvement to content and rules on Electronic health record.
Technical data items were collected related to health information in electronic records of print and electronic texts, scientific and professional literature review related to electronic health records, Web Community Health Information Management online databases and journals in selected countries (AHIMA, NHS, DOH, Medline).
Data Analysis Method
Data Analysis has performed as formal text analysis and conducted under a set of qualitative research.
After collecting, separation information sort on classified data in selected countries and classified as three matrices.
Ethical Issues
1. Principles of trusteeship have been observed particular extracted content in translations in all of the texts contained in this study.
2. The results has being provided for later use and continuing the research process of electronic health records
Results and Discussion
Review of electronic health records data sets in the U.S. classified in the following three groups, Personal data (Table1), Clinical data (Table2), Administrative data (Table3)
Review the results of data collection for electronic health records in England Obtained as follows:
1. British health service (National Health Services) a copy of required data manual for electronic health records has been developed, but do not possible to achieve because it was not printed or any electronic version was available.
2. a package of computer data and medical records needed in computer systems has designed to access by Ministry of Health in England that any electronic version was available.
3. British Health Service (NHS) in the definition of electronic social care records minimum data set of mental patients in the healthcare field, has suggested that detailed information about the service recipient, service provider, treatment programs, mental health medical care, hospital sector and conventional psychiatric admission data for inpatient care and discharge after inpatient care in this collection has been considered.
4. Electronic health record one of the important projects implemented in Europe is a priority intelligence requirements of patients in 2008 in electronic health records in Europe and especially England is as follows:
• Profile
• Information related to acute admission
• Discharge Summary
• Referral letters
• nurse assessment of health plan
• General assessment framework
• emergency care and treatment
• care related to the before and after birth
• Mental Health
• history of pulmonary heart disease
• respiratory diseases such as asthma, chronic pulmonary diseases, lung cancer
• changes in bowel function or bowel cancer
• Impact
• Diabetes
• Orthopedic problems such as knee pain and femoral
• vision loss, cataracts
Conclusion
The results of this study showed that although the U.S. has more attention the content of electronic health records has all the information that a person’s health needs in the field of data collection and approved by American Health Information Management Association that has been presented but in order to offer a comprehensive The result of this comparison is necessary to provide the database design based on the documentary belongs to HISO 10011.2 Health Information Standards Organization. HISO, a comprehensive e-government project in the country used in New Zealand and one of the aspects of promoter This project has been mentioned in the original pattern and that is necessary given the current medical records or combining localize it according to standard HL7 and DICOM. It can be a good regional instrument for integration between health service providers.
[i]. Johns. Health Information Management Technology. USA, AHIMA, 2008.
About the Author
*Mohammadjavad Hoseinpourfard, Ph.D. Student of Reseach Management in Medical Sciences
Digital Undergound “Humpty Dance”