Vázquez LH, Martínez CR, Blázquez DC, Castañeda SR

Idioma: Español
Referencias bibliográficas: 47
Paginas: 44-53
Archivo PDF: 475.69 Kb.

RESUMEN

El presente artículo trata de la necesidad de instrumentar un expediente clínico electrónico universal como una herramienta crucial en la construcción de un sistema de gestión hospitalaria más eficiente y confiable, capaz de interconectarse con un sistema de salud pública electrónico. En México existe una norma oficial del expediente clínico, la cual es la base para la formulación de un expediente clínico electrónico universal. El beneficio principal de crear una versión estandarizada del expediente es el cimentar las bases que apalanquen un esquema de salud pública electrónico, con los retos y beneficios que esto conlleva. La norma mexicana del expediente clínico no es suficiente para la instrumentación de un expediente clínico electrónico estandarizado y tampoco cuenta con un sistema informático adecuado para la administración del mismo. Por lo tanto, es necesario considerar aspectos claves como una nomenclatura médica estandarizada que incluya enfermedades, procedimientos clínicos, procedimientos médicos y estándares de transmisión de datos: médicos, clínicos y de imágenes. A lo anterior se debe sumar el factor humano, ya que si los profesionales de la salud no adoptan los nuevos sistemas electrónicos o si la población los rechaza, el gobierno se enfrentaría ante una barrera difícil de superar. También se discuten algunos de los aspectos legales que regulan y/o hacen falta para regular la instrumentación del expediente clínico electrónico. Finalmente, se hace una revisión de las posibles ventajas de que México cuente con un sistema de salud pública basado en un expediente de este tipo.

REFERENCIAS (EN ESTE ARTÍCULO)

1. 1 Sek AC y cols. A Territory-Wide Electronic Health Record – from Concept to Practicality: the Hong Kong Experience”. Stud Health Technol Inform 2007; 129 (1): 293-96.

2. Cheung NT y cols. Principles-Based Medical Informatics for Success – How Hong Kong Built One of the World’s Largest Integrated Longitudinal Electronic Patient Records. Stud Health Technol Inform 2007; 129 (1): 307-10.

3. Fung V y cols. Building a Womb-to-Tomb Health Record in Hong Kong – an Application of Information Architecture. Stud Health Technol Inform 2007; 129 (1): 474-77.

4. Weitzel M, Smith A, de Deugd S, Yates R. A Web 2.0 Model for Patient- Centered Health Informatics Applications. Computer 2010; 43 (7): 43-50.

5. SAS Institute, “Combating Health Care Fraud (Whitepaper)”. Cary, NC: SAS Institute, 2010.

6. Siau K. Health Care Informatics. IEEE Transactions on Information Technology in Biomedicine 2003; 7 (1): 1-7.

7. Hannah KJ, Ball MJ, Edwards MJA. Introduction to Nursing Informatics. 3ed. Ney York: Springer Verlag, 2006.

8. Li M, Pickering BW, Smith VD, Hadzikadic M, Gajic O, Herasevich V. Medical informatics: an essential tool for health sciences research in acute care. Bosnian Journal of Basic Medical Sciences 2009; 9 suppl1: 34-9.

9. Reiner BI, Siegel EL. The Clinical Imperative of Medical Imaging Informatics. Journal of Digital Imaging 2009; 22 (4): 345- 47.

10. Bowman S. Coordinating SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems. Journal of AHIMA 2005; 76 (7): 60- 1.

11. Yoo SK, Kim DK, Kim JC, Park YJ, Chang BC. Implementation of a largescale hospital information infrastructure for multi-unit health-care services. Journal of Telemedicine and Telecare 2008; 14 (3): 164–66.

12. Little DR y cols. Moving toward a United States strategic plan in primary care informatics: a White Paper of the Primary Care Informatics Working Group, American Medical Informatics Association. Informatics in Primary Care 2003; 11 (2): 89–94.

13. Kuwata S y cols. Effective Solutions in Introducing Server-Based Computing into a Hospital Information System. Stud Health Technol Inform 2009; 143: 435-40.

14. Herasevich V, Pickering BW, Dong Y, Peters SG, Gajic O. Informatics Infrastructure for Syndrome Surveillance, Decision Support, Reporting, and Modeling of Critical Illness. Mayo Clin Proc 2010; 85 (3): 247-54.

15. Nagy P. Open Source in Imaging Informatics. Journal of Digital Imaging 2007; 20 Suppl 1: 1-10.

16. Lindner SA, Davoren JB, Vollmer A, Williams B, Landefeld CS. An Electronic Medical Record Intervention Increased Nursing Home Advance Directive Orders and Documentation. Journal of American Geriatrics Society 2007; 55 (7): 1001–1006.

17. Johnson M., Benbow SM, Baldwin RC. An electronic patient record system and geriatric psychiatry: considerations and implications. Aging Mental Health 1999; 3 (3): 257-63.

18. Knaup P, Pilz J, Thalheimer M. Can Temporary Paper-Based Patient Records Sensibly Complete an Electronic Patient Record?. Stud Health Technol Inform 2006; 124: 207-12.

19. Charters K. Challenges of Electronic Medical Record Extracts for a Personal Health Record. Stud Health Technol Inform 2009; 146: 197-201.

20. Jones DA, Shipman JP, Plaut DA, Selden CR. Characteristics of personal health records: findings of the Medical Library Association/National Library of Medicine Joint Electronic Personal Health Record Task Force. J Med Libr Assoc 2010; 98 (3): 243-49.

21. Jang BM y cols. Design and implementation of the system architecture for sharing medical information based HL7-CDA among hospitals by the XDS model of IHE. IFMBE Proceedings 2007; 14 (Pt 6): 460-63.

22. Hellesø R, Ruland CM. Developing a module for nursing documentation integrated in the electronic patient record. Journal of Clinical Nursing 2001; 10 (6): 799-805.

23. Epstein BA, Tannery NH, Wessel CB, Yarger F, LaDue J, Fiorillo AB. Development of a clinical information tool for the electronic medical record: a case study. J Med Libr Assoc 2010; 98 (3): 223-27.

24. Pollak VE, Lorch JA. Effect of electronic patient record use on mortality in End Stage Renal Disease, a model chronic disease: retrospective analysis of 9 years of prospectively collected data. BMC Medical Informatics and Decision Making 2007; 7: 38.

25. Hing E, Hsiao CJ. Electronic Medical Record Use by Office-based Physicians and Their Practices: United States, 2007. National Center for Health Statistics Reports 2010; (23): 1-11.

26. Meredith J. Electronic patient record evaluation in community mental health. Informatics in Primary Care 2009; 7 (4): 209–13.

27. Makela K y cols. Electronic patient record systems and the general practitioner: an evaluation study. Journal of Telemedicine and Telecare 2005; 11 Suppl 2: S2:66–68.

28. Shield RS, Goldman RE, Anthony DA, Wang N, Doyle RJ, Borkan J. Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation. Annals of Family Medicine 2010; 8 (4): 316-26.

29. Loomans ER, Snoeijen M, Scholten D, ten Dolle H. Health information exchange on a regional level: dream or reality?. Stud Health Technol Inform 2006; 124: 461-66.

30. Gagnon MP y cols. Implementation of an electronic medical record in family practice: a case study. Informatics in Primary Care 2010; 18 (1): 31–40.

31. Klehr J, Hafner J, Spelz LM, Steen S, Weaver K. Implementation of Standardized Nomenclature in the Electronic Medical Record. International Journal of Nursing Terminologies and Classifications 2009; 20 (4): 169-80.

32. McGuire MR. Incorporating an EPR System with a Universal Patient Record. J Med Systems 2006; 30 (4): 259–67.

33. Seeley BE, Introducing a Computer- Based Electronic Record: Perceptions Of Clinicians. Society of Urologic Nurses and Associates Urologic Nursing 2009; 29 (5): 329-35.

34. Antohi R, Ogescu C, Stefan L, Raureanu M, Onofriescu M, Toma M. Management of the Electronic Patient Records in the Web Based Platform for Diagnosis and Medical Decision for Optimization in Healthcare-PROMED. Stud Health Technol Inform. 2007; 127: 98-107.

35. Varlamis I, Apostolakis I. Medical Informatics in the Web 2.0 Era. New Direct. in Intel. Interac. Multimedia 2008; 142: 513–22.

36. Jaspers MW, Peute LW, Lauteslager A, Bakker PJ. Pre-Post Evaluation of Physicians’ Satisfaction with a Redesigned Electronic Medical Record System. Stud Health Technol Inform. 2008; 136: 303-8.

37. Fox J, Johns N, Rahmanzadeh A. Protocols for Medical Procedures and Therapies: A provisional Description onf the PROforma Langage and Tools. Conference Proceedings of the Artificial Intelligence in Medicine in Europe 1997: 21-38.

38. Elevith FR. SNOMED CT: Electronic Health record enhances anesthesia patient safety. Journal of the American Association of Nurse Anesthetists 2005; 73 (5): 361-66.

39. Robles J. The Effect of the Electronic Medical Record on Nurses’ Work. Creative Nursing 2009; 15 (1): 31-5.

40. Kesänen J, Asteljoki S, Pykälämäki H, Korpela SV, Montin L. The Utilization of Electronic Patient Record in Pain Management from the Perspective of Nursing Management. Studies in health technology and informatics 2009; 146: 171-173.

41. El-Kareh R y cols. Trends in Primary Care Clinician Perceptions of a New Electronic Health Record. Journal of general internal medicine 2009; 24 (4): 464-68.

42. Fins JJ. Web of Care: How Will the Electronic Medical Record Change Medicine?. Hastings Center Report 2008; 38 (5): 36-8.

43. Benson T. Principles of health interoperability HL7 and SNOMED. Springer, Health Informatics Series, 2010.

44. Parry D, Parry E. Medical Informatics in Obstetrics and Gynecology. Information Science Reference (an imprint of IGI Global), 2009.

45. Lehmann C, Kim GR, Johnson KB. Pediatric Informatics: computer applications in child health. Springer, Health Informatics Series, 2009.

46. Fajardo-Dolci G, Rodríguez-Suárez FJ, Campos-Castolo EM, Carrillo- Jaimes A; Zavala-Suárez E; Aguirre-Gas, HG. Análisis de las quejas derivadas de las prácticas quirúrgicas. Cirugía y Cirujanos 2009; 77 (3): 207-15.

47. Chang F y cols. Bigtable: A Distributed Storage System for Structured Data. Proceedings of the 7th conference on USENIX symposium on operating systems design and implementation 2007; 7: 205-18.