Сеченовский университет перешел на электронные медицинские карты

Sechenov University switched to electronic medical records


Company “1C: First Bit” has completed the implementation of the system “1C: Medicine. Hospital” at the Sechenov University Clinical Center. The new system covered 1500 workers in 15 treatment and diagnostic sites
units.

The University Clinical Center employs over 5,000 employees. Provision of inpatient, rehabilitation, sanatorium and outpatient medical care is carried out in 15 units
Clinical Center located in different parts of Moscow and Moscow region.

Previously, the administrators of the Clinical Center’s registry have recorded patients admitted to a paper journal. Doctors spent 5-15% of their time designing medical cards, a daily slip
patient movement records, diary records, preoperative epicrises, protocols of operations. Diagnostic and laboratory test data were manually copied. For example, for execution
One biochemical blood test – from appointment of indicators to their registration and transfer of the doctor – took from 3 to 5 hours. Because of this, the clients of the center had to wait long for the next reception and
turn.

Clinical center has become necessary information system that would allow to store information about patients, work with electronic medical cards (EHR), provide in one base
prompt access to EHRs for doctors and patients. It was necessary to expedite registration of epicrises and protocols, diagnosis, collection of information about the patient for further analysis of his medical history.
To reduce the number of examinations by insurance companies, errors in the design of medical documents had to be eliminated.

For the implementation of the project, the management of the medical institution appealed to the company “1C: First Bit”. To solve these problems, the system “1C: Medicine. Hospital” was chosen.

The new system made it possible to achieve the following results:

  • Patients’ medical cards are now being issued electronically. The system has created over 200 medical document templates (CMD): written and stage epicrisis, preoperative epicrisis,
    diary entry / bypass, consult, oncology consult, spermogram, cryopreservation protocol of embryos and oocytes, physician consultations and more. e.) and over 3,700 completed phrases to fill
    SMD. Doctors can send the most frequently used phrase messages and hide the phrases they don’t need. As a result, the time for medical documents to be cut is halved –
    from 40 to 20 minutes. EMC filling has doubled.

  • Information about each patient is available at any time to any doctor in each of the 15 units of the facility. From the map you can get information about the results of medical examinations, about
    established diagnoses and prognosis of the development of diseases, about methods of rendering medical care and the associated risk, information about possible types of medical intervention, its
    consequences and outcomes of assistance. Several specialists of the clinic can study the contents of the EHR at the same time. It is possible not only to read the card at the same time, but also to read it
    filling.

  • If the patient is not coming for the first time, his previous medical history is immediately extracted from the archive. The doctor can promptly review it and move it to a new medical history of the disease information.
    Where it is necessary to refer the patient to any study, the passport part (passport data, policy number) is automatically collected from previously entered patient information and
    testimony to the study. According to these data, the patient is given a referral.

  • The procedure for hospital discharge is simplified. The system has all the necessary information for this purpose: the data of the initial survey, surveys, analyzes and consultations, protocols
    surgeries, etc. The written epicrisis is filled twice as fast: earlier it took 35-40 minutes, now – no more than 20. In addition, if the patient is seeking medical help again after
    discharge, the doctor can quickly raise the medical history and choose the right tactics at the stage of treatment.

  • Management of the medical laboratory of the center is optimized. Laboratory analyzers are used to carry out the research. The system automatically transmits received
    assignment to the analyzers as tasks and translates the results obtained from the analyzers into electronic patient charts in a uniform data format. This saves doctor time – data
    diagnostic and laboratory tests are transferred to the ETC one button per 1 minute, errors in the recording of results are eliminated.

The control over the correctness of filling in medical documents and the quality of providing medical assistance to patients were also strengthened:

  • There was an opportunity to promptly record, fill in the medical records and print the mandatory protocols of medical commissions, including “Protocol subcommittee examination
    temporary disability “,” Protocol of the medical control subcommittee “,” Protocol of the subcommittee on the study of fatal cases “). Work with protocols is simplified, for example, in the” Protocol of medical
    commissions “, as in other protocols, implemented buttons” Assistant “About the patient’s status. Data from the patient’s diary is automatically transferred to the protocol. If the patient needs expensive
    drug, insurance company is required to show a protocol for this drug. The program will recall the need to complete such a protocol in advance.

  • Quality assessment of medical services provided to patients is performed in accordance with the order of the Ministry of Health of the Russian Federation of May 10, 2017 № 203n “On approval of quality assessment criteria
    In the system it is carried out in 2 stages. On the first the doctor compares the criteria of the order with the real situation and notes in the system what is done that is not. On the second the head
    department or deputy chief physician for clinical expert work checks in the system properly prepared documents, whether all points of the protocol of the medical commission are filled, or received
    the patient’s consent to the provision of medical services. If the controller sees a mismatch, he promptly opens the patient’s electronic medical record and transfers the necessary data to the protocol.

  • A report has been created to track doctors’ medical records on outpatient clinics. As a result, mistakes are eliminated and the insurance company will make the full payment as well
    the medical facility will not incur unnecessary costs.

  • A report has been created showing filling errors. For example, a daily journal entry is not filled in, there is no mandatory operative epicrisis before the operation protocol, the stage epicrisis is NOT
    is filled every 10 days, the paper was not subjected to mandatory examination by the head. As a result of mistakes are eliminated in a timely manner, problems with payment from insurance
    there is no company, the funds are received on time and in full.

medicine, Electronic document management

1C | 1C

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