The EMR ( HCE), also known as electronic medical record (EMR), is a species within the genre of history and record for the machining of social data, and preventive health of a patient, obtained directly or indirectly and constantly updated. 1
Overall, l to history is the set of documents containing data, assessments and information of any kind, on the situation and the clinical course of a patient over care process. is constituted by the set of documents, both written and graphic, which refer to episodes of health and illness of a person, their medical history and health activity that is generated because of these episodes.
History electronic medical
The electronic medical record is to incorporate the Information Technology and Communication (ICT ) in the heart of health activity. The consequence is that the story ceases to be a record of information generated in the relationship between a patient and a professional or a health center, to be part of an integrated clinical information.
The electronic medical record Registration is unified and personal multimedia , which is filed electronically all the information about the patient and their care. It is accessible, with appropriate constraints (confidentiality), in all cases in which medical assistance is needed (emergencies, primary, specialty, hospital revenue , interconsultation, etc.).
to integrate all the multimedia information used in clinical practice. Properly store this information, kindly make accessible, properly disseminated to potential uses and with due guarantees ( consent, confidentiality , safety and other requirements), and receive and reuse in the most convenient way is a process still in power. 2
Problems of conceptualization of the care process and the deployment of ICT, and has not been shown to impact positively quality of clinical care, or the morbidity and no mortality in . In addition, there are problems with the coding rules and standards. 3
Using HL7 standard for EHR software
While Hospital Information Systems (HIS) or Clinical Information Systems (CIS) not to standards to facilitate the electronic exchange of data, it is possible that information is available at the point of care where the patient, regardless of the provider institution where health care is addressed.
HCE Using shared by many institutions and the multiple use of electronic documents that make the EMR, regardless of the software platforms they use, makes necessary information systems used by institutions providing health services, implement internationally recognized IT standards in order to ensure the integrity and readability of information.
The set of health information standards more developed and more international coverage, to make it possible to use the HL7 EHR is .
has HL7 message specifications, electronic documents and controlled vocabularies for health domains such as Clinical Document Architecture (CDA) Medical Records (Medical Records), Laboratory (Laboratory) Medication (Medication), diagnostic imaging and DICOM integration (Imaging Integration Domain), Bank of blood, tissues and organs (Blood, Tissue and Organ); Provision of Care (Care Provision) , etc.
HCE Other standards
Besides HL7, there are a number of EHR standards, among them:
- ↑ Gérvas J, Pérez Fernández M. Electronic medical records in primary care. Clinical rationale, theoretical and practical. SEMERGEN. 2000, 26 (1) :17-32.
- ↑ Gérvas J. Excessive expectation about the early implementation of electronic medical records. SEMERGEN. 2000, 26 (1) :3-4.
- ↑ Gérvas J. The electronic medical record: a lot of promises and little action. Aten Primaria. 2008, 40 (Suppl 1): 13.
- Pastor Sánchez R, López Miras A, Gérvas J. Computerized medical record. Med Clin (Barc). 1994, 103:304-9.
- Pastor Sánchez R, López Miras A, Gérvas J. Evaluation of computerized medical records. Med Clin (Med). 1996, 107:250-4.
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