THE POSSIBILITY OF USING ELECTRONIC MEDICAL RECORDS FOR CLINICAL OBSERVATION

Abstract

Currently, healthcare practice generates data exchange and stores a huge amount of patient-specific information in electronic medical records (EMC) and auxiliary databases. EMC used in normal clinical practice, can now be used for clinical research. The various methods available for obtaining data during research projects, in particular from integrated EMCs, have some unique capabilities. Of course, there are problems and obstacles to expanding the use of EMC, and one of the solutions to these obstacles is to address issues of semantic compatibility, privacy, and security. The collective efforts of numerous international associations involved in the development of standards have led to the emergence of standards for both the structure and the semantics of clinical information that provide semantic compatibility between different systems. It is always necessary to remember that when using EMC for clinical trials, it is first necessary to integrate various types of information, in accordance with the criteria for acceptability of the protocol, elements of clinical trial data, EMC data for only one purpose – to enable cohort identification. Electronic control systems should be able to exchange information through the use of recently published international standards for their compatibility and clinically proven information structures to ensure consistent complete recording and data exchange between different patient groups. Such systems eliminate obstacles when using various clinical languages and documentation styles, as well as recognized incomplete routine entries. Under these conditions, research projects can use data on patients from various EMC systems from various medical institutions, as well as in international multilingual environments.