Historia clínica informatizada: 8 años de experiencia en un servicio médico quirúrgico

Abstract

Background The use of Electronic Health Records (EHR) has been irregular due to having to overcome barriers to their introduction. We describe our 8 years experience in using EHR to monitor quality control in the Urology Department of a tertiary Hospital. Methods Retrospective analysis of the development and implementation of the EHR from 2001 to 2008 and the structural changes in the health care process and their results. Structural changes involved the introduction of computer terminals at all point where Health information is generated. In the Health care process a consensus was reached on coding diagnosis (221) and treatments (110), making it easier to gather information in the future. Health care registers have been simplified with pre-written texts in Anamnesis (6), Diagnosis and treatment (8), Interventions (11), and in-hospital treatments (15). Furthermore there are documents such as Informed Consents, (21) recommendations or information documents (10). A total of 5,571 discharge reports have been generated, 54,616 specialised surgery reports and 17,186 out-patient tests. Analysis of the EHR data enables us to study health care activity (extracorporeal lithotripsy, nosocomial infection, repetition of processes, etc.), specific problems (repeating prostate biopsies, increases in vesical surgery, etc.) or results of a technique (prostate biopsies, incontinence surgery, etc.). Conclusions An EHR with multiple functions enables us to have accessible guides to clinical practice, a less variable clinical practice and better information on the patient. Being able to analyse data and to study the results of health activities, EHR is becoming an essential tool in improving health care.