Medical Informatics 1MD012, Fall 2012 | Division of Visual Information and Interaction, HCI
Documentation and Medical Records
Paper-based and Computer-based
Bengt Göransson
bengt.goransson@it.uu.se
Bengt Göransson
User Centered Systems Design, Usability & Interaction Design
Employed at a GE Healthcare , Bio-Technology in Uppsala.
Part time researcher at Uppsala University.
Been working as researcher and consultant in the IT business since 1984.
Started out as a developer. Computer science background. Moved on to user-centered design and usability.
Domains: business support (public authorities, case-handling, medicine), products (hard- and software), web-applications, e-services, etc..
Developing methods: user-centered systems design in practice, e.g. a new discipline in the RUP. Scrum and usability.
Currently at GE Healthcare working on the usability for laboratory
instruments for protein purification and related areas. Also processes for
User Experience Design.
19121212 1212
Patient Svensson, Sven Byt patient Avanc. sök… Varning
Blodsmitta Vårdåtagande
Vårdåtagande VårdkontaktVårdkontakt
Välj uppgift Dokumentera Under 1 Under 2 Under 3
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Remiss och svar »»
Ny beställning Lab.-listan Resultat
Patientöversikt»»
Läkemedelslista»»
Journaltorget »»
Under 1 Under 2
Journaltorget
Dokumentera Patientöversikt Läkemedelsöversikt
Översikt »»
Visning »»
Hälsoproblem »»
Aktuella diagnoser »»
Aktuella diagnoser Aktuella diagnoser »»
Aktuella recept »»
Aktuella recept Aktuella recept »»
Aktiviteter »»
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2006-01-21 15:01 |Dr. Annika Kovacs |
19121212-1212 Svensson, Sven|2004-08-11 Vårdåtagande… xx MenyMenyMeny Hem Under 1 Under 2Hem Under 1 Under 2
Agenda Dagbok
mediPal – huvudsida 14.45
Status 16.00: 1 tbl Madopark Depot 25mg 17.30: Rörlighet
18.00: 1 tbl Madopark Depot 25mg 19.30: Rörlighet
20.00: 1 tbl Madoprak Depot 25mg 12.02: 1 tbl Madopark Depot 25mg 13.55: 1 kopp kaffe
14.10: 1 tbl Madopark Depot 25mg Spontan registrering
Övriga…
Rörlighet Smärta
1 missad påminnelse
Åtgärda Flytta Avstå Vila…
Agenda Dagbok
mediPal – huvudsida 14.45 mediPal – huvudsida 14.45
Status 16.00: 1 tbl Madopark Depot 25mg 17.30: Rörlighet
18.00: 1 tbl Madopark Depot 25mg 19.30: Rörlighet
20.00: 1 tbl Madoprak Depot 25mg 12.02: 1 tbl Madopark Depot 25mg 13.55: 1 kopp kaffe
14.10: 1 tbl Madopark Depot 25mg Spontan registrering
Övriga…
Rörlighet Rörlighet SmärtaSmärta
1 missad påminnelse
Åtgärda Flytta Avstå Vila…
KAMS Inloggad som: handläggare, Bengt Göransson Personliga inställningarHjälp xxLogga ut
Portalen Mitt arbete
Klienter Senaste
Rapporter Inkorgen
Scheman Tidsbokning
Admin Uppföljning Sök på allt
Mitt arbete
Mina senaste klienter Min vecka
Mina nya ansökningar/remisser Mina dokument
Min nästa bevakning
Uppdaterad Namn Personnr Status
2006-09-10 Per Persson 720315-1425 Deltagare 2006-09-10 Lars Larsson 630920-1415 Intressent 2006-09-09 Anna Andersson 810127-1425 Deltagare 2006-09-07 Bente Bengtsson 551117-1415 Avslutad
Dag Datum Tid Ämne Plats
Tisdag 09-19 08.30 – 12.00 Infomöte Sal A 13.00 – 15.00 Enskilt möte Mitt rum Onsdag 09-20 08.00 – 17.00 Nätverksmöte Sal B Torsdag 09-21 10.00 – 12.00 Annat möte Rum 317 Fredag 09-22
Måndag 09-25 08.00 – 10.00 Nätverksmöte Sal B
Inkom Typ Namn Avs handläggare Min
2006-08-30 Remiss Karin Persson Hans Håkansson X 2006-09-01 Uppdrag Lars Nilsson Ann Ek 2006-09-09 Egen Maria Andersson
2006-09-10 Remiss Albin Bengtsson Hans Håkansson X
Dokumentnummer Dokumentnamn
2006/300560-1 Kallelse Nätverksmöte 2006-09-25.doc 2006/24891-12 Presentation ny organisation.ppt 2005/05003-2 Förslag till förändring.doc 2006/88307-7 Protokoll från 2006-07-21.doc 2006/800325-5 Utvärdering Frans Olsson.doc 2006/343423-9 Brev.doc
Förfallodatum Namn Vad
2006-10-01 Östen Karlsson Revidering insatsplan 2006-10-12 Jakobina Fransson Uppföljning av insats
Mina meddelanden
Mottaget Ämne Avsändare
2006-09-19 08.25 Mötet börjar 08.30 Lisa Pettersson 2006-09-19 08.09 Tårta 10.15!!! Evert Andersson 2006-09-19 07.13 Ny ansökan Gunilla Ekström
KAMS Inloggad som: handläggare, Bengt Göransson Personliga inställningarHjälp xxLogga ut
Portalen Portalen
Mitt arbete Mitt arbete
Klienter Klienter Klienter Senaste Senaste
Rapporter Rapporter Rapporter Inkorgen Inkorgen
Scheman Scheman Tidsbokning Tidsbokning
Admin Admin Admin Uppföljning Uppföljning Uppföljning Sök på allt Sök på allt Sök på allt
Mitt arbete
Mina senaste klienter Min vecka
Mina nya ansökningar/remisser Mina dokument
Min nästa bevakning
Uppdaterad Namn Personnr Status
2006-09-10 Per Persson 720315-1425 Deltagare 2006-09-10 Lars Larsson 630920-1415 Intressent 2006-09-09 Anna Andersson 810127-1425 Deltagare 2006-09-07 Bente Bengtsson 551117-1415 Avslutad
Dag Datum Tid Ämne Plats
Tisdag 09-19 08.30 – 12.00 Infomöte Sal A 13.00 – 15.00 Enskilt möte Mitt rum Onsdag 09-20 08.00 – 17.00 Nätverksmöte Sal B Torsdag 09-21 10.00 – 12.00 Annat möte Rum 317 Fredag 09-22
Måndag 09-25 08.00 – 10.00 Nätverksmöte Sal B
Inkom Typ Namn Avs handläggare Min
2006-08-30 Remiss Karin Persson Hans Håkansson X 2006-09-01 Uppdrag Lars Nilsson Ann Ek 2006-09-09 Egen Maria Andersson
2006-09-10 Remiss Albin Bengtsson Hans Håkansson X
Dokumentnummer Dokumentnamn
2006/300560-1 Kallelse Nätverksmöte 2006-09-25.doc 2006/24891-12 Presentation ny organisation.ppt 2005/05003-2 Förslag till förändring.doc 2006/88307-7 Protokoll från 2006-07-21.doc 2006/800325-5 Utvärdering Frans Olsson.doc 2006/343423-9 Brev.doc
Förfallodatum Namn Vad
2006-10-01 Östen Karlsson Revidering insatsplan 2006-10-12 Jakobina Fransson Uppföljning av insats
Mina meddelanden
Mottaget Ämne Avsändare
2006-09-19 08.25 Mötet börjar 08.30 Lisa Pettersson 2006-09-19 08.09 Tårta 10.15!!! Evert Andersson 2006-09-19 07.13 Ny ansökan Gunilla Ekström
Name of System Status Details
Support
Run
Name of System Status Details
Support
Run
Bengt Göransson
User Centered Systems Design, Usability & Interaction Design
Brainstorming
Talk in groups two and two.
Questions:
- What is medical documentation and a medical record?
- Why is it important with medical documentation?
- Who is documenting?
After Today…
• You will know what a care process is
– Example from primary care and hospital
• You will know more about medical records
– What it looks like – Who is documenting
– What kind of information it contains – How it can be structured
• You will understand some problems with paper-based and
computer-based medical records
The Generic Care Process
• The patients way through healthcare, from sick to healthy.
Initiating Diagnosis Prognosis Therapy End
Medical Documentation
• Important part of the care process
• In the medical record
• Relevant fact, findings and observations about an individual's health history including
– past and present illnesses – examinations
– tests
– treatments
– outcomes
The Care Process in Primary Care (swe. vårdcentral)
The patient has a problem
Examination and initial diagnosis Meets physician
Calls primary
care, to get advice from eg. a nurse
The patient is healthy
Referral to specialty care, or treatment at primary care
Decision about treatment,
start the treatment
Doctors vs. Nurses
• Doctors diagnos and treat patients
• Nurses give care to patients
”Nurses care for the sick and injured in hospitals”
• When a person becomes ill or is injured, generally the doctor assesses the patient, diagnoses the patient's
problem and decides on the treatment needed to cure the problem or relieve the patient's symptoms.
• Today, however, nurses play a large role in evaluating
patients and detecting problems. In some rural areas,
nurses admit patients to hospital and manage their care,
referring only the most critical patients to distant medical
centres.
Hospital (Specialty care)
Registration process
• Patient information – administrative and clinical data
• Initial examination – anamnesis* and clinical examination
• Decision on care commitment; is the patient at the right care unit?
Diagnostic process
• Actions: tests and examinations
• Make a diagnosis
• Decision about treatment / therapy
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions,
either of the patient or of other people who know the person and can
give suitable information.
Hospital
Treatment / therapy
• Treatment / therapy plan
• Treatment / therapy actions
• Result?
Discharge process
• Epicrisis; a critical or analytical summing up of a medical case history
• Prognosis; the prospect of recovery as anticipated from the usual course of disease or peculiarities of the case
• Re-use documented data
• Follow-up
A Patient’s Clinical Picture
Time
Health issues Contacts
What is a Medical Record?
• A Medical or Patient record is a systematic documentation of a patient's medical history and care
• It contains:
– Administrative data – Anamnesis
– Status
– Diagnostic actions – Test result, x-ray – Diagnosis
– Therapy plan
Goal with Medical Records
• Collect relevant data for supporting
– Treatment
– Decision making – Evaluation
– Quality making – Research
– Education
• Better quality of the care process
• Give the patient the best care possible
Legally Required to Document
• Physicians – in the medical record
• Nurses – nursing documentation
• Allied Health Personnel
– Psychologist
– Physiotherapist
– Welfare officer
VIPS − Documentation Aid For Nurses
• Tool / model for a high quality and secure nursing documentation
• VIPS (swe. Välbefinnande, Integritet, Prevention och Säkerhet. In eng. Well-being, Integrity, Prevention and Security)
• Documentation to support caring
Structure of Medical Records
Time
Oriented
Strucure of patient records
Time Oriented
Problem
Oriented
Problem Oriented Medical Record (POMR)
S ubjective O bjective A ssessment P lan
Structure of Medical Records
Time Oriented
Problem Oriented
Source
Oriented
Paper-based Medical Record
Negative
• One place at a time
• Missing records
• Unstructured
• Hard to read
• Hard to get a good overview
• Many different records
• Quality assurance is difficult
• Hard to archive
Hard to archive…
Electronic Medical Record (EMR)
Often used in primary care, less used at hospitals
• Access to all information
• Easier to make a clinical picture
• Don’t need to search for the record
• The patient don’t have to explain everything every time
• Reuse test result
• The same structure for all documentation
Not So Great With EMR
• Low usability
• The computer is not working
• Slow computer programs
• Same structure for all care providers
• Bad authorization systems
• Not one patient one record
Patient Data Act
(swe. Patientdatalagen)
• The purpose of the Patient Data Act is to improve patient security and protect sensitive data.
• Requirements on
– Security
– Documentation
– Rules for secrecy and accessibility
• All care providers (are legally responsible to follow the
patient Data Act)
Multiple computer systems
• Multiple systems for primary care
• 5 dominant systems for the whole care process in Sweden:
– TakeCare (Profdoc)
– Cambio Cosmic (Cambio) – Melior (Siemens)
– VAS (Norrbottens läns landsting)
– BMS Cross (SYSTeam)
Market Shares
Example: Cambio COSMIC
Concept: One patient – One medical record
• Clinical care support
– Care documentation
– Order management (e.g radiology, lab, consultations….) – E-prescription
– Birth, Craft (surgery), Emergency, Link
• Patient administration system (PAS)
– Resource planning
– Patient management
Example Screen: Select Patient
Read Records, Referels
Write Records
Patients At A Care Unit, Ward
Medical Informatics 1MD012, Fall 2012 | Documentation and Electronic Medical Records| November 2012 © 2012 Bengt Göransson | bengt.goransson@it.uu.se
