Electronic patient records and electronic health records in Family Medicine
Creators: name: Oksuz, Ergun
Publisher: name: figshare
Year: 2021
Subjects: subject: 111706 Epidemiology
subject: FOS: Health sciences
subject: FOS: Health sciences
subject: 119999 Medical and Health Sciences not elsewhere classified
subject: FOS: Other medical sciences
subject: FOS: Other medical sciences

description: ELECTRONIC PATIENT AND ELECTRONIC HEALTH RECORDS IN FAMILY MEDICINE <br>Electronic patient registration systems cover an entire healthcare institution that provides healthcare services. They have a single patient registration number and an integrated clinical data system. They allow all healthcare providers within the institution to enter data directly into the computer. Such a system must provide confidentiality, security, countability, data integrity, and liability features.In addition to all the features of electronic patient registration systems;It is a system that enables all organizations providing organizational, national, and international health services to access health and patient records. To establish such a system, it is necessary to develop a unique national and/or international identification number system related to patients, healthcare institutions, healthcare paying institutions, infrastructure, technology, and standards that can exchange information between different systems.STANDARDS FOR ELECTRONIC HEALTH RECORDS* Clinical specificity* Defined message fields* Code sets* Financial transaction standards* Sharing of information / ensuring compliance between requests (interoperability)* Standard expression of medical concepts* Security, privacyChallenges for electronic health records; legal regulations, standards, trust, compatibility between systems, documentation, technologies. Electronic health records are created at the birth of individuals. It ensures that their health can be maintained and improved throughout their life and that they can be treated in the most effective way when they get sick. Electronic health records can be protected either over a private health network or by various security mechanisms.They are also known as "Virtual Health File" since they are accessed over the internet, and they have a distributed structure.A country to create and use general-purpose and comprehensive electronic health records; national health information infrastructure and index, health information reference models, standards that determine the structure, content, and standards of medical files, and most importantly; must ensure that health information is taken from its source accurately and completely and that it is stored in a standard structure in the institutions' own health records.PATIENT DATAElectronic health record systems are based on patients' data. It supports reaching time-oriented, source-oriented, and problem-oriented. Creating problem-oriented patient records requires clinical staff to clearly define patient problems and the relationships between the problem and findings. One of the main themes in creating electronic health records is data entry and presentation in the records.DATA INPUTThere are two main strategies for collecting data in a structured way:* Natural Language Processing (NLP)Natural language processing method, free texts entered in an electronic environment; it is to be fragmented and stored in a structured and coded form by means of software containing a medical terms dictionary and language structure information (syntax, synonyms, etc.). The simplest form of natural language processing produces an index of the terms used. This type of index is used to search or recall texts that contain one or more specified terms. In the best case, natural language processing technology can obtain as much data as a human can in a limited number of areas. In addition to the advantage of natural language processing not to restrict clinical staff to describe their findings with appropriate sentences, it also has the disadvantage that it cannot guide healthcare professionals to be more detailed and clear in their descriptions.Current applications for the natural language processing system are more reliable and efficient when the area covered is limited, such as in radiology reports.<br>* Structured Data Entry (SDE)One main strategy for obtaining data in a more complete and more specific way is to enter data directly in a structured manner, using interfaces developed for this purpose. Since no one can expect healthcare professionals to use large guidelines stating which terms can be used in which contexts and in which combination, data entry with structured data entry, it is essential that the software supports the users as much as possible.<br>* Data entry formsIn some cases, only a limited number of fields need to be specified within a particular medical specialty or framework of a particular study. It can be efficient to combine these fields in one or two forms. Thus, the data entry process is reduced to filling these forms.<br>Electronic health record systems should support structured data entry for a wide variety of fields of medicine. The form-based approach is not suitable for such a purpose. Given the possibility of detecting small and unpredictable findings in a patient, the number of potential findings is enormous. An all-encompassing approach requires the use of multiple forms to accommodate all potential findings. When users have to search many forms, they may move away from the whole picture and conclude that structured data entry is insufficient.<br>* Dynamic structured data entryIf the data entry area is wide and the findings to be entered are unpredictable, dynamic forms should be designed. This means that the forms are shaped automatically according to the subject of interest. Such as using interactive screens, menus, icons, or a combination of these to achieve dynamic forms, there are different techniques.In some cases, the combination of a natural language processing system with structured data entry may be beneficial.<br>INFORMATION STANDARDS IN HEALTHEnsuring compliance of electronic health records with medical record system based on a paper file system, Sharing information within and between institutions, Integration of different systems,Standards are required to enable the development and use of decision support systems.