Implementation of the Outpatient Online Clinical History for ASSE

The State Healthcare Service Administration (ASSE for its acronym in Spanish) is the main comprehensive healthcare provider in Uruguay. With a service network covering the whole national territory, it contributes to improving the quality of life of its beneficiaries and leads the healthcare model changes in accordance with the premises set forth by the National Integrated Healthcare System.

Requirements

The institution required a new, user-friendly Online Clinical History that considered all of the healthcare team working at the primary level of care and all of its dependencies.

Solution

HCEA, a problem-oriented online clinical history, was developed together with a mobile application that can be used offline, in accordance with the healthcare needs presented in the care situation.

Both solutions are compatible with all of the architectural standards and requirements established at both national and international levels. These systems were integrated with the National Online Clinical History, both when sending CDAs and when viewing them.

Scope

The application is web responsive, which allows for it to be used on PCs and on tablets, and makes it possible for the health team in the primary level of care to enter the care records. The use of the application allows for user to:

  • View the patient’s summary with all relevant history details.
  • Access the patient’s clinical history, including healthcare events registered in ASSE and events for other institutions.
  • Recording of the patient’s background information and medical alerts.
  • Recording of consultations (with a specific sheet depending on the age range).
  • Recording of pregnancy control consultations, following the code of the SIP sheet. 
  • Recording of any pediatric control consultations. 
  • Alerts engine with the possibility of configuring them, whether to meet healthcare goals, for screening purposes, or for healthcare policies defined by ASSE.
  • Recording of procedures, including procedures performed within a consultation.
  • Prescription of medications integrated with ASSE’s pharmacy systems.
  • Prescription of inter-consultations integrated with the Consultation Management System (SGC for its acronym in Spanish).
  • Prescription of procedures integrated with the Consultation Management System (SGC for its acronym in Spanish).
  • Integration with the Consultation Management System. Users can now receive generated orders, schedule both spontaneous and consolidated consultations in SGC, and get the daily report.
  • Recording of house calls and visits.
  • Recording of Teacher/Resident activities.
  • Indicators for each healthcare member. For example: percentage of use of the tool, or epidemiologic profile for their patients.

Management and Audits:

  • The application has an audit of every action performed. There are several different audits and reports for control and tracking purposes.
  • The medical records section has several specific options such as:
    • Access to the user clinical history within ASSE (permission-based)
    • Printing of the HCE for ASSE users.
    • Printing of Healthcare Control Certificate.
    • Update of patronymic user data (integrated with the ASSE user registry).
    • Loading of notifications, visible once the user accesses the application. This allows for several different profiles for the target users, keeping track of who viewed them.
    • Audit indicators, for the audit profiles or management team of each unit. Several indicators and reports were defined for tracking purposes.
    • Master medication chart composed by DINAMED, which allows for the medication to be managed and integrated into a permission and restriction-based engine.

The HCEA application allows users to:

  • View the patient summary, including all details relevant to the patient’s history.
  • Access to the patient’s clinical history. All healthcare events registered in ASSE are included, such as the ones the patient sees in HCEN.
  • Record the patient’s background with codes, including patient alerts.
  • Record a consultation (with a specific date for the age ranges)
  • The application also works in offline mode. 

Within the project’s framework, a new architecture was implemented, with the XDS and reception of CDAs from all existing clinical systems in ASSE.

Results

The web application has been implemented in all of ASSE’s healthcare units. It has a high degree of usage and user acceptance, and is constantly evolving.

The HCEA application has fixed issues with the provision of healthcare in remote locations with very low or no connectivity, such as rural rounds of healthcare for persons deprived of their liberty within prisons.

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