Name: Age: Date: MRD No:

Transcription

1 ELECTRONIC MEDICAL RECORDS - A NEW PARADIGM Dr. Y.M. Fazil Marickar, MS, MAMS, PhD (Urology), FAMS, FAS, FIMSA, FEMSI. Principal, Mount Zion Medical College, Former Professor and Head, Department of Surgery, Govt. Medical College Thiruvananthapuram, India Abstract Most electronic medical records programs in hospitals are either defunct or incomplete due to inadequate data entry. In order to circumvent these causes for failure of the system. This program has been created by the doctors as templates for various diseases and the programmers have been asked to create the platform to suit the requirement of the doctors. The highlight of the program is the creation of the large data bank to form the template for the diagnosis, investigations and treatment of common diseases. When a patient attends the OPD, the doctor makes a diagnosis and selects that from the template. More than 10,000 templates are created for the different disease conditions. The appropriate diagnosis has to be selected from the template. Minor changes can be made in the selected template to suit the present patient. The investigations to be done and the treatment to be given are predetermined, based on the hospital policies. The cost envisaged for investigation and treatment will be automatically calculated. Automated IP case sheets, doctor s orders, nurses records and charts, operation notes, discharge summaries, certificates etc are all predetermined. There also provision for patient education and student education, which link to folder for the diagnostic condition and contain files in the form of word, photos, power point, video and audio files. All the files can be prepared and kept as input. The advantages include simplicity, completeness, uniform investigation and treatment policies, patient education and student education. The hospital becomes paperless and spelling and grammar problems in the patient records are totally eliminated. Keywords: Electronic Medical Recording, templates, Out patient card, In patient case sheet, doctor s orders, nurse s record, investigations, treatment, operation notes, discharge summary, economics. Full text, with all subsections and illustrations INTRODUCTION Electronic medical records are very common in most new generation hospitals in the world. However, most of the programs are either defunct or incomplete. One has to ask many questions to understand the reason for the failure - How many are being run properly? How many hospitals are paperless as yet? How many doctors are using the program regularly? How many hospitals have made a total list of names, diagnosis, case sheets, lab investigations, pharmacy, operative procedures, doctor s orders and nurses records? The answer will be recognised spontaneously. The Problem has to be analysed. The main cause for failure is the lack of involvement of the doctors in proper data entry. This is because the doctors are not computer savvy. The EMR program is usually created by non medial computer programmers in their own language, which is ill understood by the doctor fraternity. The program is thrust 1

2 Presenting Complaints: Epigastric pain & abd. Bloating off & on - 6 mths upon doctors, leading to failure of the system Further, the Medical terms are difficult to handle resulting in deficiencies in the platform of the program. Similarly computing terms are alien to doctors. So the learning curve for doctors is very tall. What is new in this EMR? In order to circumvent these causes for failure of the system, a new program has been created. Here the doctors have created the templates and the programmers have been asked to create the platform to suit the requirement of the doctors Modules Out Patient Module In Patient Module Investigation Module Pharmacy Module Operation Theatre Module Intensive Care Module Discharge Module Total Patient Module Order Of Occurrence Out Patient Module Blank screen. MRD Number / Name from template. Diagnosis from template. OP ticket fills up. Modifications in case sheet made. Investigations selected. Treatment selected. Print out given to patient. OP Pages Log In Page Department MRD Number / Patient Name Diagnosis Full Page Of OP Card A5 Completed Edit Data, Investigations, Treatment Dispose Or Admit Save And Print Sample Case Sheet Name: Age: Presenting Complaints: C/o - 1 week History: General Examination Pallor: absent. Icterus, Oedema, Clubbing, Cyanosis - Nil Temp. Normal, Pulse: 68 / minute. BP: 124/82. Systemic Examinations CVS: NAD RS: NAD GIT: NAD Local Examination DIAGNOSIS: Investigations: Rx ACID PEPTIC DISEASE 2

3 If You Want To Admit Click Admit IP Case Sheet are already available as templates. The case sheet for the particular diagnosis will be automatically filed from template. Minor modifications will have to be done by the junior doctors to suit the present patient. When modifications are made the modified case sheets are converted top new templates. Doctor s Orders are already available as template. 3 Presenting Complaints: Swelling right groin - 6 months History: Started as minimal pain in the right groin. Patient noted a swelling on coughing or laughing. No H/o bowel discomfort or urinary symptoms. H/o DM 10 years and HT 7 years. Is on OHA

4 Nurses Reports are also prepared as templates for selection appropriately. This avoids the usual English grammar and spelling mistakes seen in all manual medical recors. Furtehr it si awaste of time for the nursing staff writing all details. Recording parameters like pulse, blood pressure, temperature, fluid chart, insulin sugar chart, drug chart etc are filled electronically. During the follow up in the out patient department or in the wards, the patient parameters are filled in the format of the tables shown below for different situations like thyroid profile, diabetic status, hypertensive status, glomerulonephritis, deep vein thrombosis, appendicitis etc. Reports os status of urinary stone disease and report of the KUB, Ultra sound scan etc can be recorded in tabled formats. Once Surgery is performed, the previously prepared templates for operative procedures as shown below are utilised. MOUNT ZION MEDICAL 4 COLLEGE HOSPITAL, Chayalode, Adoor, Pin Date:

5 MOUNT ZION 5 MEDICAL COLLEGE HOSPITAL, Chayalode, Adoor, Pin

6 MOUNT ZION MEDICAL COLLEGE HOSPITAL, 6 Chayalode, Adoor, Pin Date:

7 MOUNT ZION MEDICAL COLLEGE HOSPITAL, 7 Chayalode, Adoor, Pin Date:

8 MOUNT ZION MEDICAL 8 COLLEGE HOSPITAL, Chayalode, Adoor, Pin

9 9

10 MOUNT ZION MEDICAL COLLEGE HOSPITAL, Chayalode, Adoor, Pin Date: Name: Age: REPORT OF KUB REGION Plain x-ray KUB / USS / IVP / CT Scan / Renogram / Endoscopy Provisional Diagnosis: Findings: Final Diagnosis: MOUNT ZION MEDICAL COLLEGE HOSPITAL, Chayalode, 10 Adoor, Pin Date:

11 MOUNT ZION MEDICAL COLLEGE HOSPITAL, Chayalode, Adoor, Pin Date: Unique No: Name: Age: STONE PATIENT STATUS Parameter Value Score Total duration

12 MOUNT ZION MEDICAL COLLEGE HOSPITAL, Chayalode, Adoor, Pin Date: Name: IPSS (modified) BPH Age: Test Value Score Difficult to postpone 0-5 Push / Strain to begin 0-5 Weak urine stream 0-5 Stop in between 0-5 Incomplete Emptying 0-5 Urinate again within 2 hours 0-5 Number at night 0-5 Total Score 0-35 Diagnosis : Hemithyroidectomy Pre operative Diagnosis: Solitary Nodule 12 Thyroid Right. II. Post operative Diagnosis: Solitary Nodule Thyroid Right. III. Surgery Proposed: Hemithyroidectomy Right. IV Surgery Performeed: Hemithyroidectomy Right. V. Anaesthesia: General VI. Position of Patient:

13 Trendelenburg Operation I. Pre operative Diagnosis: Varicosity of long saphenous vein II. Post operative Diagnosis: Varicosity of long saphenous vein III. Surgery Proposed: Trendelenburg Operation IV Surgery Performeed: Trendelenburg Operation V. Anaesthesia: Spinal VI. Position of Patient: Supine Trendelenburg position VII. Incision: VIII. Findings: Oblique incision just below the groin crease starting from femoral arterial pulsation to 5 cm medially. IX. Steps of Operation: 1. Skin flaps reflected 2. Long saphenous vein identified below groin. 3. Tributaries of long saphenous vein - superficial epigastric, superficial circumflex iliac and superficial external pudental ligated and divided 4. Long saphenous vein ligated flush with the femoral vein. 5. Upper two inches of saphenous vein excised. X. Closure: Haemostasis obtained, Skin closed, Elastocrepe bandage applied XI. Drain: Tube suction drain. XII. Specimen for Histopathology: Nil. Appendicectomy I. Pre operative Diagnosis: Acute 13 appendicitis II. Post operative Diagnosis: Acute appendicitis III. Surgery Proposed: Appendicectomy IV Surgery Performeed: Appendicectomy V. Anaesthesia: Spinal VI. Position of Patient: Supine

14 Hernioplasty I. Pre operative Diagnosis: Indirect Inguinal Hernia Right. II. Post operative Diagnosis: Indirect Inguinal Hernia Right. III. Surgery Proposed: Hernioplasty right. IV Surgery Performeed: Hernioplasty right. V. Anaesthesia: Spinal VI. Position of Patient: Supine VII. Incision: Half an inch above and parallel to medial 2/3 of inguinal ligament. VIII. Findings: Direct Inguinal hernia. IX. Steps of Operation: 1. Skin and superficial fascia incised along the line of incision. 2. External oblique cut in the line of its fibres. 3. Cremasteric fascia cut and sac identified. 4. Plication of fascia transversalis. 6. Lichtenstein repair done by fixing prolene mesh with interrupted size 0 prolene sutures. X. Closure: External oblique closed with interrupted vicryl. Wound closed in layers. XI. Drain: Nil. XII. Specimen for Histopathology: Nil. Operative Procedure template helps the students in many ways; Pre operative learning process. The students can read the steps of operation before starting the 14

15 witnessing of the operation. Time not lost for the junior doctors writing operation notes. Students are prompted to learn procedure. Proper recording of operation notes in case sheet will be helpful to keep proper medical records. Discharge Summary is pre designed discharge summary. So there is no need to wait for junior doctor. Discharge medicines predetermined. So the Discharge process can be made fast.made fast. Basic Concept Soft ware person creates PLATFORM for the templates. Doctors make their own TEMPLATES and modify by themselves. Every new case adds to the template. The Significance Saves time. Complete print out on paper. No missing of clinical tests. Investigations to be done are predetermined. Cost of investigations shown. Which medicine to prescribe. Spelling of medicines (very difficult). Cost of medicine. Basic Data - Templates Names Diagnosis Investigations Medicines Surgical procedures Doctor s orders Nurses reports IC guidelines - policies Hospital Policies Decision on investigations for individual conditions. Policy decisions on treatment protocols. Protocol for students Cost factors RSBY patients Poor patients Cost effectiveness Uniform policy Duplication Of Records? 15

16 First patient take from template. Second patient modify template item and save as number two. eg. Appendicitis 1, Appendicitis 2, Appendicitis 3, Appendicitis 4, Appendicitis 5 and so n depending upon the severity of the appendicitis. Mistake Free New diagnosis should be entered and added. Every new item of template should be verified before adding to program list. Conclusions OP Give Print out. Admission filled up case sheets. Fill up progress notes and doctor s orders. Cost can be assessed before prescription. Operation notes are ready made. Nurses record. Investigation results. Discharge summary Print out. Learning Process For Students OP cards will have clear patient data. IP case sheet will be filled on admission; so students can verify their case sheets. Doctor s orders will be in exact order. Investigations are not missed. Operative procedures will be complete. Trainee surgeons can revise steps before. Post op orders are predsigned. Discharge summaries will be ready made. Problems During Rounds No case sheet. Solution - Junior doctor or sister learns and prepares reports. - IPAD / Laptop during rounds. - Consultant sits in front of computer and decides the changes. - Print out is taken of doctors orders. Take Home Message It is possible to standardise a Medical Record System by doctors themselves. IP Records can be paperless. If one does not have a well organised programme, many of these are possible on ordinary word files, provided the doctors create templates. 16

17 Author s biography (200 words) BIO DATA OF DR. Y.M. FAZIL MARICKAR Dr. Fazil Marickar MS, MAMS, PhD (Urology), FAMS, FIMSA, FAS, FEMSI is Principal, Mount Zion Medical College. Has beensurgical teacher for 43 years and has done extensive research on urolithiasis, completed 42 funded research projects of the ICMR, CSIR etc., presented 130 international and 850 national papers and published 389 papers and seven books. He has guided eleven Ph.Ds. He delivered the Pandalai Oration of ASI and was the first doctor to receive the Fellowship of the Electron Microscopic Society of India and Indian member of the International Consulting Committee on Urolithiasis. He is Inspector of MCI expert panelist of the Kerala State Council for Science, Technology and Environment. He was the best doctor of Kerala in He is President of Association of British scholars, Secretary of NAMS, Governing Council Member of ASI, Editorial Board Member of Urological Research and peer reviewer for many international journals. He was nodal officer medical curriculum for Kerala, Chairman of the ASI Kerala Chapter, President of ASI Trivandrum branch, Vice President of Urolithiasis Society of India, Secretary of Urological Association of Kerala, Editorial Secretary of Urolithiasis Society of India and editor of Kerala Surgical Journal. Author s postal and address Dr.Y.M. Fazil Marickar, Principal, Mount Zion Medical College, Shamier Manzil, Mosque Lane, Kumarapuram, Trivandrum fazilmarickar@hotmail.com 17