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Electronic Health Record
Electronic Patient Records
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Updated: 2009/05/07
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Information Manual
 
 

 

The Electronic Patient Record (eHR™.ZA) is designed to store information about the health of an individual.

Information from a variety of health care providers is collected and stored in a single record, providing a complete and accurate record of the key elements of an individual's personal health history. The protocol used to transfer data is HL7, which is an International standard for formatting, transmitting and receiving data in a healthcare environment.

Importantly, the individual decides who may or may not see information pertaining to previous health encounters. Because the system operates via the Internet, individuals have on-line access to their own personal Electronic Health Records.

Health care providers are able to access patient records at the point of a clinical encounter. This ensures that health care providers have important information about their patients' health and health care histories, enabling them to provide the best possible healthcare program. Diagnoses, treatments and outcomes will be vastly improved when health care providers have access to individual health information and can link that information to clinical support tools, as they become available.

The use of the eHR™.ZA will result in improvements in clinical processes, work efficiency, and continuity of care. Increased cost savings can also be achieved. For instance, having access to recent test results can provide huge cost savings by avoiding duplicate test requests.

Security and confidentiality will be improved as precautions have been put into place to ensure that the eHR™.ZA only grants access to those people who have a need to know and are duly authorised. This is mainly achieved by the use of fingerprint technology to ensure that the user is authenticated and it is also the means by which the patient grants consent.

The eHR™.ZA can produce benefits in managing chronic and infectious diseases by expanding the information available in the electronic health records to the primary health care level. The ability also exists for the linking of disability and welfare information into the record of an individual.

Electronic health and welfare records can provide aggregate data that can be used in health research and surveillance, programs such as PMTCT or ARV, tracking disease trends and monitoring the health status of the population.

The quality of health care delivery can be improved. The eHR™.ZA enhances the ability of managers and researchers to identify and react to problems that occur in the health care system, and improve patient safety and quality of care.

Lastly, patients can play a role in the management of their own healthcare, by being better informed about their conditions and their treatment plans.



 

 

 

Is the eHR™.ZA suitable for HIV clinics and monitoring ARV rollout?

The Electronic Patient Record service (eHR™.ZA) is designed to capture the encounter of a patient with a healthcare provider. There is no minimum set of clinical data to be captured, making it ideal to implement any kind of encounter details.

This makes it suitable for use in a situation where only the coded diagnosis (ICD-10) from an encounter is required, or where just a laboratory result or a dispensed medicine needs to be recorded.

In addition, assessment, examination, measurements and results are all templates that are user-configurable, and can vary per location and/or per specialty.

Thus in a scenario where an HIV clinic visit is being recorded, only the place, the date/time and the medic are captured, together with the information defined for the protocol in use at that clinic.

The advantage of the design of the system is that when the patient attends a different clinic, or is referred from the clinic to a hospital, the information concerning their clinic visits is available to the hospital.

In the example of the HIV clinic referral, this means that the hospital is aware of the patients CD-4 count, viral load, HAART regimen and any notes made at the clinic, irrespective of the quality of the referring letter from the clinic.

The service is web-based and derives it's inputs from existing operational systems, or from the web-based screens where no operational systems exist. The other point to note, is that only a PC with an internet browser at the clinic is needed to input or view this information. In addition, the service is hosted inside the South African government network, SITA, thus there are no internet connection charges for a clinic that is connected to the provincial 'OpenNet' network.

Obviously security and confidentiality in such a situation is of paramount importance. This has been addressed by means of a biometric fingerprint solution, to ensure that both users and patients are correctly identified. This also serves as the mechanism for patient consent.

Off-line ART capture program

There is also an off-line version of the ART system available. The idea is that plenty of clinics have a PC but few have reliable connections, making it difficult to use the on-line web-based system for data collection.

The off-line version of the program establishes no database at the site, making it easier to be installed and maintained. Instead, it acts very simply as a patient visit data capture tool, and saves the captured data to HL7 messages in text format. These can then be sent by email if there is a line available, else physically sent by stiffy, CD or memory stick to a regional/district office for transmission to the server, which sits inside the Government SITA network.

Once this data is in the eHR™.ZA system, the regional/district offices can extract their monthly reports through the browser interface, including the National and DORA reports, and treatment sites(most of these do have communications) have the patient treatment details available, no matter which clinic the patient attended previously.

There is no cost for using the system whatsoever, not for the off-line capture program nor for the repository and web-based use of the data.

Please contact info@ehr.co.za if you are interested in a copy of this program.

 

 

 


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