A very important criterion for assessing the quality of a medical information system (MIS) is the degree of formalization of the medical data stored in it. But this «degree of formalization», of course, should be reasonable and convenient for the doctor working with the medical information system, providing the opportunity to detail the entering medical information to the required level.
The level of formalization of medical data accumulated in the MIS on one‘s problems can be determined by any specialist independently — on the basis of the requirements of legislation, guidelines, medical standards, one‘s own experience, as well as the requirements of the medical organization in which one works.
So what formalization is and why it is given such attention in our medical information system «Alpha:Medicine» — let‘s see more.
The simplest general definition of formalization:
Formalization (from latin "forma" — form, image) is a representation (mapping, marking, naming, description) of objects in a particular subject area using symbols of any language.
Language of formalization for our medical information systems «Alpha:Medicine» is a pair of elements "Name":"Value", describing the condition of the patient, method of its treatment and any other medical information about the patient accumulated in the MIS as for a textual representation in electronic and printed medical, and for its later analysis.
It is the ability to analyze formalized data characterizes their main and significant advantage over text data. And, of course, a very serious advantage of medical formalized data is the possibility of forming easily readable electronic medical documents in which the medical information, formalized at the input stage, is transformed into a cohesive, well structured, easy-to-read text. This advantage greatly facilitates the perception and interpretation of medical data, both on the computer screen and on paper carriers and, of course, solves the problem of impossibility of reading difficult-written manuscript documents.
In our medical information system «Alpha:Medicine» formalized data is entered and stored in electronic medical records, called "electronic formalized medical protocols". Actually, these protocols represent the notorious EPMR (Electronic Personal Medical Records), creating patient‘s EMRs (Electronic Medical Records) stored in the database of the medical information system. The formalized data themselves are called "elements of the electronic formalized medical protocol" and are described in our information system by a set of characteristics that determine the type and properties of each element. Among these characteristics can be listed: the name of the element, the compulsory completion of the element, the presence of the header element, the norms of the input values and many others. But the main characteristic of each element, of course, is the "form of information input into the element".
15 forms of input of medical information in the MIS «Alpha:Medicine»:
In our medical information system «Alpha:Medicine» there are 15 forms of information input for elements. Among them there‘s input of numerical and text values, selection and input of dates, selection of values from lists, selection of values from database structures of the information system (from nomenclators, classifiers and directories — All-Russian, international and domestic), the choice of logical values, the loading of pictures and others. Control Panel «Alpha:Medicine» has a special service-designer that allows you quickly and easily to create "electronic formalized medical protocols" from the elements added to them and to change them.
The information entered into the items of the "electronic formalized medical protocol", after its saving, is stored in the database of the information system in a structured form and is transformed into the text of the protocol if it is necessary to display it on the screen — both for reading and for subsequent printing as a paper document. The information storage organized in this way provides the opportunity for detailed analysis of medical data entered by physicians — both for medical statistics, and for medical analytics and science.
After editing and saving "formalized electronic medical Protocol" in our medical information system «Alpha:Medicine», it becomes easily readable electronic medical document. And the quality of this document in the first place depends on the completeness of the information entered into it by the doctor.
It is to ensure the completeness of medical information that the elements of the protocols of our medical information system «Alpha:Medicine» can be configured as mandatory for filling, and also as dependent ones — i.e. to provide for the obligation to fill certain elements, depending on the selected values in the previous elements. This setting is done in the management service "electronic formalized medical protocols" in the control panel of our medical information system «Alpha:Medicine» and does not require any programming — everything is done through the interface of the MIS. Both the doctors themselves and the specialists in the maintenance and operation of MIS participate in this setup, helping doctors correctly use the capabilities of the information system. At the same time, the process of configuration of protocols, their finalization, improvement and optimization is carried out by doctors constantly, independently or together with specialists in the maintenance of the information system, because medical science does not stand still — new knowledge and new techniques require not only the ability to apply them, but also the skills to describe them correctly.
Very convenient tools that help the doctor to enter medical information into "electronic formalized medical protocols" in our medical information system «Alpha:Medicine» is the mechanism of their autocomplete, minimizing the actions of the doctor to enter data into the protocol. One of such mechanisms is the ability to use templates, which allows automatic filling in of protocols with template values, according to the subject of the selected template. Besides, it is possible to automatically fill in the newly created protocols on the basis of information about a previous examination of the patient and/or treatment.
The possibilities of formalizing medical data in our medical information system «Alpha:Medicine» is given maximum attention. After all, our task is to give the doctor a tool for everyday work and the more qualitative and convenient it will be, the better and faster the doctor will perform his uneasy direct work without being distracted by paperwork. But is this our main task? Certainly!
P.S.: In this article we did not talk about many other solutions we used to organize work with the patient‘s electronic medical record in our medical information system «Alpha:Medicine». Among these solutions there are the security of access to medical data, and the opportunities used to sign (and re-sign) medical data, and the possibility of using "electronic text medical protocols" with templates, and many other solutions that you can read about in other materials on our website. Our experience is long-term, we are ready to share it and acquire a new one, in cooperation with you.
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Module MIS «Alpha:Medicine» that provides planning of laboratory research, their implementation and delivery of results to the doctor‘s workplace. Provides bar-coding of test tubes and interaction with laboratory analyzers
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