“Evaluate HSJ-ICU system use by medical doctors” Turma 20 Professor Orientador: Ricardo Correia

Introduction

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 Medical record [1]

Paper Medical RecordsElectronic 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 Lesser losses and duplicity of information Legibility Consistencie of information (format and localization) Internal structure Help in the management of medical resources Support medical investigation and education Share information The acess is restricted [5] [4] [1] [6] [1]

In Hospital de São João (HSJ)… SONHO (Sistema de Gestão de Doentes Hospitalares) Administrative data General clinical information (SAM – Sistema de Apoio ao Médico) Reduced flexibility Lack of specification Implementation of different Departamental Information Systems (DIS) Share of clinical information using PMR Unrelated DIS Duplicated data High administrative costs (time and staff) [3] [1] [3] [7]

Virtual Electronic Patient Record (VEPR) Integration in one interface of several DIS Clinical information of the patient in one single folder ICU (Informação Clínica do Utente) VEPR Integration of the various DIS with SONHO Collection of the information for a central base in report form Available for reading by medical doctors through the intranet of HSJ [9] [8] [3]

It’s available to the users for about one year Since then its use has been increasing To evaluate the reasons for use or non-use of HSJ’s ICU system by medical doctors at HSJ ICU… Objective [3]

References 1. Aula sobre Registos Clínicos Electrónicos do Curso de Informática Médica que se encontra em 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, 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): Coiera E. Guide to medical informatics, the internet and telemedicine. Arnold Publishers, London, Uckert F. et al. Functions of an electronic health record. INT J Comput Dent Apr-Jul; 5 (2-3): Lenz R and Kuhn KA. Integration of heterogeneous and autonomous systems in hospital. Business Briefing: Data management & Storage Technology, 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

Flowchart Flowchart

Gantt Chart

Questionnaire