Electronic Health Record for Intensive Care based on Usual Windows Based Software.

Area of Science:

• Medical Informatics
• Clinical Information Systems
• Healthcare Technology

Background:

• Intensive Care Units (ICUs) generate vast amounts of patient data requiring efficient management.
• Existing Patient Data Management Systems (PDMS) and electronic health records (EHRs) face challenges with reliability and proprietary software.
• The need for customizable and reliable data management solutions in ICUs is critical for patient care and review.

Purpose of the Study:

• To develop a flexible EHR system for an ICU environment.
• To avoid vendor lock-in associated with proprietary healthcare software.
• To create a system that meets the specific data processing and review needs of an ICU.

Main Methods:

• Designed a client-server architecture utilizing the Windows operating system and Microsoft Access database.
• Developed the client interface using Visual Basic, incorporating functions for medical notes, observations, treatments, and nursing charts.
• Integrated scoring systems for patient classification and modules for encoding medical activities for billing.

Main Results:

• The developed EHR system has been operational since September 2004, managing care for over 5,000 patients.
• The system demonstrated expected software reliability, facilitating data management and review processes.
• Initial communication with other medical software was achieved through basic functionalities; future upgrades include multi-platform support and enhanced features.

Conclusions:

• The custom-built EHR system successfully addressed the medical data management needs of the local ICU.
• Development on the Windows platform enabled customization to the existing organizational structure, enhancing user acceptance.
• The use of standard software components proved effective for creating a functional and adaptable ICU electronic health record system.