Aims and content of the Electronic Medical Records in Primary Care: A different approach
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1 Aims and content of the Electronic Medical Records in Primary Care: A different approach Dr Dimitris Kounalakis, General Practitioner, Research Associate, Medical School, University of Crete
2 Electronic Medical Records: Definition The systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction Contains: observations, administration-orders of drugs and therapies, test results, x-rays, reports, etc over time that are electronically archived and retrieved. Questions about sensitive personal information
3 Why EMR in Primary Care is different? Long time lasting episodes of care Reason for Encounter Different situations, unique requests More prevention and statistics, less blood and radiation First diseases' symptoms are not typical EMR includes also organisational and billing information for small health units
4 Episode of care Health problem health care is needed Request for Encounter Exams, Diagnosis Interventions, Medication Episode of Care It is a medical problem from its first presentation to health care personnel until the last encounter that the patient receives health care for that. Request for Encounter Exams, Diagnosis Interventions, Medication Iassis Death New episode Episode of disease: Medical problem from its beginning (asymptomatic) until Death or Iassis. Episode of illness: The time period that the patient suffers.
5 Primary Care and classifications A48.1 Legionnaires' disease J10.0 Influenza with pneumonia, influenza virus identified J11.0 Influenza with pneumonia, virus not identified J12.0 Adenoviral pneumonia J12.1 Respiratory syncytial virus pneumonia J12.2 Parainfluenza virus pneumonia J12.8 Other viral pneumonia J12.9 Viral pneumonia, unspecified J13 Pneumonia due to Streptococcus pneumoniae J14 Pneumonia due to Haemophilus influenzae J15.0 Pneumonia due to Klebsiella pneumoniae J15.1 Pneumonia due to Pseudomonas J15.2 Pneumonia due to staphylococcus J15.3 Pneumonia due to streptococcus, group B J15.4 Pneumonia due to other streptococci J15.5 Pneumonia due to Escherichia coli J15.6 Pneumonia due to other aerobic Gramnegative bacteria J15.7 Pneumonia due to Mycoplasma pneumoniae J15.8 Other bacterial pneumonia J15.9 Bacterial pneumonia, unspecified J16.0 Chlamydial pneumonia J16.8 Pneumonia due to other specified infectious organisms J17.0 Pneumonia in bacterial diseases classified elsewhere J17.1 Pneumonia in viral diseases classified elsewhere J17.2 Pneumonia in mycoses J17.3 Pneumonia in parasitic diseases J17.8 Pneumonia in other diseases classified elsewhere J18.2 Hypostatic pneumonia, unspecified J18.8 Other pneumonia, organism unspecified J18.9 Pneumonia, unspecified J18.0 Bronchopneumonia, unspecified J18.1 Lobar pneumonia, unspecified R81 Pneumonia Criteria: απόδειξη πνευμονικής πύκνωσης Includes: bacterial/viral pneumonia, bronchopneumonia, influenzal pneumonia, Legionnaire's disease, pneumonitis Excludes: aspiration pneumonia (R99) Consider: Cough (R05), acute bronchitis (R78) ICPC-2: 2 codes ICD-10: 80 codes SNOMED-CT: 182 main codes Every ICPC-2 code points to one or more ICD10 codes
6 EMR in Primary Care in Greece EMR is mandatory by law for family doctors Primary Care Health Centers can use Hospital's EMR but almost nobody uses it. National Primary Health Network (PEDY) has no EMR A small number of Private Doctors have EMR The new on-line e-prescription system has no interoperability with EMRs
7 Which EMR for Greek primary care? Everyone has the best A NSRF funded EMR can be created Only IDIKA can do it Only EOPYY can buy it Do we need a local or a central EMR for primary care?
8 Local EMR software Adapted to health unit needs Optimized to local pathways Customized to keep information based on local population particularities Protects patient privacy External added features: On the Job Training, research, collaborations
9 Central EMR Software Central database for primary and secondary health care Health history visible to all health units & doctors Continuity among physicians Free for all users a web browser is needed Central changes, start for all users Can you give the password to nurse or reception?
10 Why not a local EMR with a central system? Different EMRs connect to a central system through an open defined protocol eg epsos A minimal dataset is defined and requested Each physician or health unit or hospital can select its EMR according to local needs and connect to central system Different software can exist for doctor & nurse Any add-on feature can exist Most countries have 2-10 different EMRs for GPs
11 Current status A national e-prescription system exists Doctors can not feed two different systems The new EMRs have embedded a web browser to automate the use of e-prescription system The EMR retrieves prescriptions through the pharmacists' protocol and other data through the web page. The prescription is automated by the EMR
12 Primary Care Health Records An EMR developed in Windows platform for primary care physicians after a collaboration between universities of Amsterdam and Crete Works solo or in network. It embeds a Chrome web browser. Retrieves prescriptions and patient's data from National e-prescription through API Uses ICPC-2, ICD10, ATC classifications for symptoms, diagnoses, reasons for encounter
13 Primary Care Health Records Records exam results, vital signs, photos, scans It includes medical calculators and reminders for preventative procedures Chronic or special diseases, vaccinations, allergies can be recorded Custom forms to enter data or research purposes A print generator for custom prints Reports to the doctor for medical & other reasons
14 Main screen
15 Comparing exam results
16
17 - Doctor, is he dead? - I'm not sure. I will try a reboot... Thank you for your attention
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