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  • EHR-S Scorecard

  • Disclaimer

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  • Product File

  • 1. Basic product information

  • 2. Basic supplier information

  • 3. General characteristics

  • 4. Models of use

  • The solution is delivered in model:

  • 5. Technology

  • 6. Support

  • Support availability
  • Support type
  • Support cost

  • 7. Integrations

  • 8. Training

  • Training options
  • Training cost

  • 9. Price

  • 10. References

  • 11. Media

  • EHR

  • Cells marked by (*) define requirements that must be complied with the EHRS.

  • General Requirements

  • The profile distinguishes the different functions of professionals, e.g. doctor, nurse, administrative, etc. The role distinguishes the different tasks of a profile. For example, admission clerk and the radiology department clerk in charge of transcribing the department's medical reports. To answer in the affirmative, it is necessary that the system distinguishes access by both profiles and roles.
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  • The affirmative answer requires both the management of the request for consultation or exploration, and the report of the result. Both must be part of the EHRS, i.e. when the request or result requires access to another application, even if it is by clicking on the EHR, the response must be negative.
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  • It is understood that the exchange of information is due to interoperability. If the exchange of information is by file transfer, e.g. Excel or similar, the answer should be negative.
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  • 1. Patient and care data

  • 1.1 Patient identification

  • A fragmented medical record is one that, while belonging to the same patient, presents records that are not connected to each other. A very classic case is the availability of independent patient records in different departments of the same hospital. It also refers to situations where departmental systems such as the laboratory are not integrated with the EHR, for example, because results are accessed through a viewer, or by accessing the laboratory system.
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  • Patient identification may use redundant procedures, such as the standardized care network identification code and the history number of each care facility. The question refers specifically to a personal identification code common to the entire care network. One question refers to the identification code within the health care network (provider organisation) and the other refers to the identification code of the entire health system, which includes all service providers.
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  • 1.2 Patient affiliation (personal data)

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  • 2. Uniqueness and registration

  • 2.1 Unique medical record

  • At any level or level of care, the doctor or nurse has a view of the patient's clinical information, even if it has been recorded in another facility or level of care (primary care, hospital or other facilities).
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  • The electronic medical record (electronic health record) does not allow a patient to be assigned to two records. When a patient is discharged, before assigning a new ID code, the system makes certain that there is no other person with that identity. This check uses data such as surname and first name, father's and mother's first and last names, date and place of birth, among others. When a possible duplicity is detected, an alert is issued to verify the person's identity.
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  • 3. Information registered in the MR

  • 3.1 Prevention and education

  • Refers to the registration in each patient's EHR of colon and breast cancer screening results, among others.
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  • This refers to the fact that there is a specific field to record the patient's ability to understand.
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  • The positive response necessarily requires a field where the patient's instructions are recorded as to who, besides him/herself if he/she is able to understand it, will receive the information.
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  • 3.2 Vaccinations

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  • Refers to interoperability with public health systems
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  • 3.3 Social data

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  • Interoperability between health and social services information systems is necessary to meet this requirement.
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  • The activity carried out in the care centres can give rise to information on the social characteristics of patients, which can be exchanged with other information systems (in the social sphere).
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  • 3.4 Consultancies

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  • The EHR is a tool whose functions include registration clinical information. The information registration needs of different medical specialties are different. For example, primary care, Ophthalmology, ENT, Maxillofacial Surgery, etc. The EHR view and registration of information must be customised to these specific needs.
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  • The EHR allows for patient care based on a list of health problems that should be resolved, not on the basis of diseases or chronologically ordered medical information. The professional from basic data, history, examination and complementary studies builds a list of medical, psychological or social problems of the patient. For each health problem identified, a diagnostic plan, a therapeutic plan and a follow-up plan are produced. In this manner the information is better organized for better decision making.
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  • The activity carried out in health care centres, in this case the outpatient clinic, can give rise to clinical information on patients, which can be exchanged with other information systems (in the health field).
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  • 3.5 Active diagnoses and patient history

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  • The activity carried out in health care centres can give rise to clinical information on patients, which can be exchanged with other information systems (in the health field).
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  • 3.6 Physiological parameters and assessment scales

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  • An affirmative answer to this question requires interoperability between the electro-medical devices and the EHR. the EHR. All the usual devices in the Intensive Care Unit must be interoperable.
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  • The activity carried out in health care centres can give rise to clinical information on patients, which can be exchanged with other information systems (in the health field).
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  • 3.7 Medical orders

  • The affirmative answer to this question requires that, both for the issuance of the most frequent medical orders and for the incorporation of the corresponding report, the paper is not necessary. The following orders, for example, are considered to be the most frequent: the care that the hospitalised patient must receive (feeding, checks, postural changes, etc.); the request for complementary examinations such as imaging, laboratories, etc.; the prescription, dispensing and administration of medicines when they take place in the same care centre; consultation with other services or other colleagues.
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  • For example, the request for diabetic profile analysis, cardiovascular risk profile, etc.
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  • In this case, the positive answer requires interoperability between systems. requires interoperability between systems.
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  • 3.8 Identification of chronic or complex patients

  • A chronic patient is defined as a patient with one or more chronic diseases. In this sense, the World Health organisation (WHO) defines chronic diseases as "conditions of long duration" (more than 6 months) "with a generally slow progression", while a complex patient (complex chronic) is understood to be one who has progressive and limiting diseases, who is polymedicated and who presents some degree of functional deterioration.
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  • Positive feedback requires interoperability between systems.
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  • 3.9 Pharmacological prescription

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  • This requirement refers, for example, to the possibility of viewing prescriptions written for the patient at other providers at the same or another level of care.
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  • 3.10 Laboratory

  • As a general rule, positive responses in this chapter require interoperability between the EHR and the laboratory information system.
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  • 3.11 Imaging

  • As a general rule, positive responses in this chapter require interoperability between the EHR and the radiology information system
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  • 3.12 Image

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  • 3.13 Other complementary tests (Except diagnostic imaging and laboratory)

  • As a general rule, the positive responses in this chapter require interoperability between the EHR and the information system of the departments or providers performing this testing.
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  • 3.14 Scheduling of activities

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  • 3.15 Last wills

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  • 3.16 Hospitalization of patients

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  • Patient care is based on a list of health problems to be resolved and not on the basis of diseases or chronologically ordered medical information. The professional, from basic data, history, examination and complementary studies builds a list of medical, psychological or social problems of the patient. For each health problem identified, a diagnostic plan, a therapeutic plan and a follow-up plan are produced. of the same. In this way the information is better organized for better decision making.
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  • An affirmative response requires that the clinical protocol or guideline be part of the EHR. That is, if a patient is identified as meeting the criteria for a particular protocol, the EHR will suggest the steps that should be taken to care for that particular patient: tests to be requested at any given moment; care to be provided, prescription of medication, etc. Therefore, it is not only a matter of incorporating a PDF file or similar with the protocol to the EHR for consultation.
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  • The activity carried out in care centres, in this case hospitalization, can give rise to clinical information on patients, which can be exchanged with other information systems (in the health field), for which interoperability between systems is required.
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  • 3.17 Emergency care

  • An affirmative response requires the EHR to have a system in place to record the clinical information needed for triage and to calculate their degree of risk or priority for care. information needed for triage and calculates their level of risk or priority for care.
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  • Patient care based on a list of health problems to be resolved and not on the basis of diseases or medical information arranged in chronological order. The professional from basic data, history, examination and complementary studies builds a list of medical, psychological or social problems of the patient. For each health problem identified, a diagnostic plan, a therapeutic plan and a follow-up plan are produced. In this manner the information is better organized for better decision making.
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  • Interoperability between the EHR and laboratory information systems is required.
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  • Interoperability between the EHR and the diagnostic imaging information system is required.
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  • The activity carried out in health care centres, in this case emergencies, can give rise to clinical information on patients, which can be exchanged with other information systems (in the health field), for which interoperability between systems is required.
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  • 3.18 Informes de atención en la hospitalización

  • The affirmative answer requires the EHR to provide patient information that should be incorporated into the report for editing by the physician signing the report.
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  • 3.19 Informed consent

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  • 3.20 Surgical treatments

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  • In this case, the positive answer implies that the checklist is registered directly in the EHR, including the signature, without the need to provide other documents (pdf, etc.).
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  • The affirmative answer requires the EHR to provide patient information that should be incorporated into the document for editing by the physician signing the report.
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  • Interoperability between the EHR and the anatomic pathology information system is required.
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  • 3.21 Non-surgical treatments

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  • Interoperability between systems and devices with the EHR is required.
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  • Interoperability and standars

  • Cells marked by (*) define requirements taht must be complied with by the EHRS.

  • 1. Standards

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  • Does the system have the ability to receive information using semantic information exchange standards recognized by official international standards (SNOMED CT, LOINC, ICD-10, for example)?
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  • Does the system have the capacity to receive information using internationally recognized terminology and classification standards (SNOMEC CT, LOINC, ICD-10, for example)?
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  • 2. Operation and monitoring

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  • Seguridad

  • Cells marked by (*) define requirements that must be complied the EHRS.

  • 1. Identification and authentication

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  • 2. Permissions and roles of actors

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  • 3. Traceability of actions

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  • 4. Information integrity, availability and confidentiality

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  • 5. Risk Management

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  • 6. Standards and regulatory monitoring

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  • Under which data protection, dissemination and authorisation regulations are they governed?
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  • Usability

  • 1. Simplicity in the navigation and organisation of the contents

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  • 2. Effective interaction

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  • 3. Design

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  • 4. Consistency

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  • 5. Help and error prevention

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  • 6. Feed-back and analytical information (Control and feedback)

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  • 7. Minimizing the need for user interpretation

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  • Should be Empty: