Oncological Electronic Medical Record

The Oncological Electronic Medical Record is an information system that contributes to improving patient care by integrating clinical information from all institutions involved in their care process, regardless of their geographical location and care institution, with a comprehensive view of the patient.

Historia clinica

Requirements

The project involves the construction of the National Oncological Medical Record, based on the K2BHealth solution. All oncologists in the country will use this medical record in all institutions across the country.

Solution

Two pilots were implemented (Hospital de Clínicas and Asociación Española) and deployment was completed in all institutions across the country, including integration with private insurers.

The main challenge of the project is to develop a user-friendly medical record, as well as the design and implementation of an architecture that allows for total integration among all healthcare institutions in the country.

Features of the Specialized Electronic Medical Record:

  • Important architecture that integrates clinical information (studies and other consultations) based on CDA documents.
  • Includes standards and interoperability mechanisms.
  • Complies with current regulations from regulatory entities.
  • Meets security criteria oriented towards patients and physicians.

Scope

A user-friendly medical record was developed following usability recommendations, and various change management and training tasks were carried out for users, including training materials.

The medical record allows for patient tracking through the following functionalities:

  • Overview of the patient's evolution.
  • Patient summary, with the most relevant elements of their medical history.
  • Structured recording of medical history.
  • Diagnosis using a terminology server, including staging.
  • Systemic treatment planning (protocol loading).
  • Radiation therapy treatment planning.
  • Compliance and follow-up of systemic treatments (including monitoring in the day hospital).
  • Compliance and follow-up of radiation therapy treatments.
  • Ateneo records.
  • Prescription of medications (integrated with ASSE’s pharmacy systems).
  • Referral Prescription (integrated with each institution's scheduling system)
  • Prescription of diagnostic and therapeutic procedures (integrated with each institution's scheduling system).
  • General indicators for each institution
  • Indicators for each oncologist.
  • Integration with HCEN.

Furthermore, the Oncological Electronic Medical Record allows for integration with the scheduling systems of each institution, and for those that do not have a scheduling system, the K2BHealth system is made available to them.

Technologies and tools

  • GeneXus con Generador Java
  • DBMS: PostgreSQL
  • App Server: Jboss
  • K2BTools
  • HL7
  • CDA
  • XDS
  • Java
  • GXServer

Results

The Oncological Medical Record is being used in all oncology services of the country's institutions, allowing access and unification of each patient's information.

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