A system for presenting and processing medical cards in primary care medical organizations

Abstract

Scientific and technological progress in health service is based on the opportune introduction of results of scientific research to medical practice, development of the material basis of health service, and education and training of skilled medical personnel [8]. In recent years there has been a considerable progress in computer-assisted medical technologies. In particular, personal computers are presently commonly used for automating processing and presentation of medical documentation, the most time-consuming and boring component of medical activities. The filling in of numerous medical accounts, reports, forms, etc. is a routine element of dally activity of any physician and health service official. From 17% (dentists) to 34% (general practitioner) of working time is spent by physicians for filling in mandatory medical forms [2]. The information stored on paper is difficultly available and, in most cases, it is not properly used. Statistical and prognostic processing of such information is very laborious and time-consuming. Because of the large volume of stored medical information, its diversity, and high probability of loss, it is rather difficult to implement medical statistics and short-term and long-term management of health service [3, 6, 7]. Computerization of medical organizations is presently often reduced to automation of administrative activity alone (general statistics, medical insurance, financial documentation, etc.). Medical activities of physicians are computerized or automated only locally (automated physician's workplaces) or as specific diagnostic hardware and software. The main disadvantage of computerization of health service is lack of a unified approach to presentation of medical documentation and standards for medical computer-assisted hardware and software. In our opinion, comprehensive automation of health service organizations should be based on unified presentation of information about patients. The patient's electronic medical card is an example of such a document. These cards contain main medical information concerning the patient: questionnaire; graphical, textual, and tabular information; classification codes, etc. In addition to the usual routine form of presentation (standard templates), these cards allow automatic processing and easy storage and access to the information. Documentation templates are stored separately from specific medical data, although printed copies are based on routine presentation. Introduction of new documents does not require the whole system to be modified [4]. This system provides the opportunity for information exchange both inside the health service organization (between individual departments, services, etc.) and between this organization and other medical institutions. This also provides a basis for the development of automated physician's workplaces and for integrating new medical programs into the system. The use of personal computers in medical organizations should be based on unified presentation of information about patients. The system of presentation and processing of medical c a r~ (SPPMC) [5] was taken in this work as a software basis of unified presentation of information about patients. On one hand, the information in this system can be presented as routine paper forms, and on the other hand, this information is available for computer processing and storage (e.g., in databases) for statistical purposes, screening, prognosis, etc. [2]. This approach to the development of the system allowed a unified tool of patient's information to be obtained. This also provided the opportunity for developing of automated workplaces of medical personnel, incorporating these workplaces into existing computer-assisted diagnostic systems, and for constructing a unified system of presentation of medical information.