patient records and usability - uppsala university · informationsteknologi institutionen för...

Patient Records and Usability

Rebecka Janols 2010-11-05

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

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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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TakeCare

TakeCare – “to do”

Take Care – “to do”- at this unit

TakeCare – “to do” with this patient

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The patient card

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My master thesis

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Health issue patient overview

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Health issue overview

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Problem 2: Safety  Secrecy  Accessibility  Correctness  Traceability

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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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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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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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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 it’s 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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Problem 4: Communication   Information in many systems

 Different architecture  Different information structure

  Integration & interoperability  Technical interoperability  Semantic interoperability

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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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Can you think of any other problems?

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Trends….  NPÖ – National Patient Overview  European Patient Overview  Medical account so the patient can get

access to her own medical record.

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Summary   The problem with the computer based medical

records are:   User interface   Safety   Terminology   Communication

patient records and usability - uppsala university · informationsteknologi institutionen för...

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