“Evaluate HSJ-ICU system use by
medical doctors”
Professor Orientador: Ricardo Correia
Turma 20
Introduction
Medical record
• Set of documents
• Clinical data
• Clinical history
• Physical examination
• Diagnosis and treatments
• Laboratorial tests
• Complementary reports of diagnosis
• Other notes made by health professionals
• Administrative data
It’s important to:
• Formulate diagnosis hypotheses
• Decide the therapeutical treatment
[1]
Paper Medical Records
Electronic Medical Records
[2]
Paper Medical Record (PMR)
Advantages:
• Familiar to users
• Easily transportable
• Do not experience downtime as computer systems do
• Flexibility
[2]
Electronic Medical Records (EMR)
They are more than single computerization of PMR
Advantages:
• Various forms of viewing and analysing the information
• Frequently up-dated
[4]
• Lesser losses and duplicity of information
• Legibility
• Consistencie of information (format and localization)
• Internal structure
[1]
• Help in the management of medical resources
• Support medical investigation and education
• Share information
• The acess is restricted
[1]
[6]
[5]
In Hospital de São João (HSJ)…
SONHO (Sistema de
Gestão de Doentes
Hospitalares)
• Administrative data
• General clinical information
(SAM – Sistema de Apoio ao Médico)
[1]
• Reduced flexibility
• Lack of
specification
[3]
Implementation of different Departamental
Information Systems (DIS) [7]
Share of clinical information using PMR
• Unrelated DIS
• Duplicated data
High administrative costs
(time and staff)
[3]
Virtual Electronic Patient Record (VEPR)
• Integration in one interface of several DIS
• Clinical information of the patient in one single folder
[8]
ICU (Informação Clínica do Utente)
• VEPR
• Integration of the various DIS with SONHO
[3]
• Collection of the information for a central base in report form
• Available for reading by medical doctors through the intranet of HSJ
[9]
ICU…
• It’s
available to the users for about one year
• Since then its use has been increasing
Objective
• To evaluate the reasons for use or non-use of HSJ’s
ICU system by medical doctors at HSJ
[3]
References
1. Aula sobre Registos Clínicos Electrónicos do Curso de Informática Médica que se
encontra em http://im.med.up.pt.
2. Richard S. Dick, Elaine B. Steen, and Don E. Detmer, The Computer-based patient
record: An Essential Technology for Health Care, National Academy Press, 1997.
3. R. Cruz-Correia, P. Vieira-Marques, P. Costa, A. Ferreira, E. Oliveira-Palhares, F.
Araújo and A. Costa-Pereira, Integration oh hospital data using agent
Technologies- A case study (2005).
4. Torchio M, Molino F, Sestero D, Seidemari C, Molino G. Na electronic madical
diary for computer assisted patient management. Minerva Med.2003 Jun; 94 (3):
167-79.
5. Coiera E. Guide to medical informatics, the internet and telemedicine. Arnold
Publishers, London, 1997.
6. Uckert F. et al. Functions of an electronic health record. INT J Comput Dent.
2002 Apr-Jul; 5 (2-3): 125-32.
7. Lenz R and Kuhn KA. Integration of heterogeneous and autonomous systems in
hospital. Business Briefing: Data management & Storage Technology, 2002.
8. Manual do utilizador do ICU
9. Panfleto de divulgação do ICU
Methods
• Type of the study: Transversal and observational study
• Target population: about 1000 medical doctors working
at HSJ
• Sampling method: simple random sampling
• Sample: 100 medical doctors
• Pilot questionnaire: applied to 4 medical doctors of HSJ
selected at random
• Questionnaire – personal structured interview:
• Evaluate the use, frequency of use, opinions and
influence of some variables (sex, age, medical specialty)
• Introduction of the data in SPSS
Start
Sample selection
Flowchart
Elaboration of the
questionnary
Pilot’s application
Is the pilot
viable?
Reformulation of
the questionnary
NO
YES
Application of the
questionnary to
the chosen
sample
Insert the results
on SPSS
Analyze
frequencies of the
answers
Analyze relations
between answers
Discussion of the
results
The end
Flowchart
Gantt Chart
Questionnaire