Electronic Health Record in Dermatology Service

In this paper we describe the implementation of an Electronic Health Record in the Dermatology service of a Portuguese hospital. This system must follow the principle of simplicity, enabling recording quality and analytical processing. Standards and norms were also followed and it is shown that interoperability has a key role in the whole process. This project is a good example of cooperation between academic and healthcare institutions and shows the impact of new technology on healthcare organizations.

[1]  Alfred Winter,et al.  Specification of a Reference Model for the Domain Layer of a Hospital Information System , 2005, MIE.

[2]  E. B. Steen,et al.  The Computer-Based Patient Record: An Essential Technology for Health Care , 1992, Annals of Internal Medicine.

[3]  Kaija Saranto,et al.  Definition, structure, content, use and impacts of electronic health records: A review of the research literature , 2008, Int. J. Medical Informatics.

[4]  José Neves,et al.  Auditing agents in the context of a telemedical information society , 2006 .

[5]  S. Kay,et al.  Medical Records and Other Stories: a Narratological Framework , 1996, Methods of Information in Medicine.

[6]  R Haux,et al.  A Requirements Index for Information Processing in Hospitals , 2002, Methods of Information in Medicine.

[7]  José Neves,et al.  Quality of service in healthcare units , 2010, Int. J. Comput. Aided Eng. Technol..

[8]  Pia Britt Elberg,et al.  Electronic patient records and innovation in health care services , 2001, Int. J. Medical Informatics.

[9]  Reed M. Gardner,et al.  Strategic Information Management in Hospitals: An Introduction to Hospital Information Systems , 2004 .

[10]  José Neves,et al.  Electronic Health Records and Decision Support Local and Global Perspectives , 2008 .

[11]  D Kalra.  ISO DIS 18308 Requirements for an Electronic Health Record Reference Architecture [31 pages] , 2008 .

[12]  Reinhold Haux,et al.  Individualization, globalization and health - about sustainable information technologies and the aim of medical informatics , 2006, Int. J. Medical Informatics.

[13]  H. Joachim Schmidt,et al.  The Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics , 2000 .

[14]  José Neves,et al.  Inter-organization Cooperation for Care of the Elderly , 2007, I3E.

[15]  Claus Bossen,et al.  Evaluation of a computerized problem-oriented medical record in a hospital department: Does it support daily clinical practice? , 2007, Int. J. Medical Informatics.

[16]  M. Musen,et al.  Handbook of Medical Informatics , 2002 .

[17]  William R. Hogan.  The Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics , 2000 .