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Sistemas De Historia Clínica Electrónica INFOLAC2008 - AAIM © 2008 - Todos los derechos reservados Evaluación de prestaciones de los Sistemas de Historia Clínica Electrónica Sergio Raúl Samoilovicha a Asociación Argentina de Internet Médica y Bioinformática **: Grupo de Informática Médica – UTN – Regional Bs.As. Resumen Introducción Los diversos sistemas apuntan a cubrir distintas necesidades Decidirse por un sistema EMR, o de Historia Clínica Informa- de los usuarios. Si bien lo ideal sería un único formato com- tizada, es una tarea difícil pero cuya trascendencia justifica patible y universal, las muchas variantes tecnológicas, cultu- una investigación detallada. Y cuánto más grande la institu- rales y hasta filosóficas impiden que hasta el momento se ción, más factores entran en juego y deben ser analizados. haya impuesto un estándar. Los niveles de complejidad de los usuarios pueden ir de un La informatización discontinua de las instituciones suele fa- médico con consultorio individual, hasta un país entero, pa- vorecer sistemas Interrelacionados, idealmente compartiendo sando por clínicas, hospitales, obras sociales o empresas de datos a través del estándar HL-7, sin superposiciones ni con- medicina prepaga. flictos, y con criterios uniformes de usabilidad y seguridad. A nivel de pequeña práctica médica el mercado incluye ofer- Al realizar el paso del soporte papel al informático en forma tas de proveedores internacionales, en general localizables por global, se pueden adoptar sistemas Integrados. Estos están en Internet. Sin embargo, en la medida en que el usuario tiene mejores condiciones de ser: mayores necesidades, pretensiones y presupuesto, el espectro • Sólidos de proveedores se achica, y empieza a influir el aspecto de presencia regional de profesionales informáticos que puedan • Modulares proveer soporte para la instalación y uso, y desarrollos a me- dida para aspectos médicos, administrativos, contables o ana- • Expandibles líticos. • Configurables El presente trabajo es un relevamiento de sistemas existentes • Versátiles para EMR, un análisis de su estructura de datos y prestacio- nes, y una propuesta de lineamientos a seguir para la toma de • Auditables decisiones por parte de prestadores médicos medianos o gran- • Seguros des que por motivos técnicos aún no hayan informatizado ple- namente sus registros médicos. • Completos Se contemplan los puntos de vista a menudo encontrados de • Permitir inteligencia de salud y de negocios los diferentes tipos de usuario (médicos y otros prestadores de salud, pacientes, administradores y analistas de negocio), y las • Satisfactorios en todos los niveles: Médicos, Adminis- prestaciones que cada uno considera prioritarias, con fines de trativos, Contables y de Calidad Integral. ayudar a los desarrolladores de software y a los implementa- • Legales dores, a crear productos completos, eficientes y de calidad. Se propone una Matriz de Evaluación que refleja estos crite- rios. Materiales y Métodos Palabras Claves Se relevaron 18 sistemas de EMR, nacionales y extranjeros. EMR, Medical Records Systems, Computerized, Historia Clí- En los casos en que fue posible, se bajó el producto y se lo nica informatizada, Historia Clínica electrónica. instaló en PC bajo Windows XP. Se recogieron especificacio- nes y prestaciones descriptas en la Web, en el manual de ayu- da de cada producto y en las pantallas del mismo. Esta investigación no fue exhaustiva, ya que no se cubrieron todos los productos ni todas las prestaciones de cada producto, INFOLAC2008 - AAIM © 2008 - Todos los derechos reservados pero se intentó definir un candidato principal para cada tipo de Se entrevistaron 15 usuarios de sistemas EMR, en institucio- usuario: hospitales de Argentina, obras sociales o entidades de nes públicas (Hospital Churruca) y privadas, a nivel particular medicina prepaga de Argentina, o médicos que ofrecen con- o administrativo institucional, en forma no estructurada, con sultoría a través de Internet. el fin de evaluar las prestaciones que cada uno valora en los sistemas EMR. La información fue obtenida de la Web, y no se verificó en todos los casos hasta que punto era válida en el momento de publicarse o sigue siendo válida actualmente. Resultados Se intentaron definir prestaciones útiles para estos tres tipos Los resultados de la evaluación de sistemas EMR se resumen de usuario en todos los softwares analizados, con el propósito en las Tablas 1 y 2, para productos en español y en inglés res- de sugerir mejoras a los productos existentes. pectivamente. Tabla 1 –Productos EMR en español URL Au- Nombre Detalle – Prestaciones Tec- Público Comenta- Pre- Acceso tor nolo- rios – cio gía usabilidad http://www.hospitalitali Hos- Historia - Sistema propio No se Miembros No es Hay que ano.org.ar/docencia/ne pital Clínica - Creación de vocabularios controlados en diferen- detalla. del Siste- u empadro- xo/attachs/1705.pdf Italia- Electró- tes dominios (prácticas Servi- ma de pro- narse en la no - nica y procedimientos, productos farmacéuticos, mate- dor Salud del ducto institución riales descartables, problemas médicos) y su corre- Htal. Depar Hospital lación con sistemas de clasificación nacional e propio. Italiano ofreci- para poder ta- Italiano internacional, integrado en un servidor de termino- Acceso BsAs – do acceder a mento logía médica. parcial Argenti- comer- una historia de - Monitor de eventos clínicos, que permite el por na.. cial- clínica onli- funcionamiento de sistemas clínicos computariza- WWW. Hispano- mente ne. Infor- dos para la toma de decisiones mediante parlantes. al ma- alarmas y recordatorios. público - Sistema Notificador de Interacciones Farmacológi- ción cas (SNIF). Hos- - Módulos de solicitud de exámenes complementa- pitala- rios y de visualización de resultados. ria - Reserva de Turnos por Internet. http://www.softwareme Conn Angel Sistema Integral de Administración de la Sa- Orienta- Usable en Gratui- Acceso a la dico.net med – lud ÁNGEL® , desarrollado durante 10 años. do prin- buena to HISTORIA Registro médico electrónico que “puede incor- cipal- parte sin CLINICA del http://www.maximocont porar datos socioeconómicos y ambientales”. mente a soporte, se paciente rol.net/ Permite administrar personal, patrimonio, Argenti- requiere desde cual- stocks de farmacia, etc. Sist. “ilimitadamente na consultoría quier Termi- http://www.connmed.co flexible” que ha permitido desarrollar módulos para su nal. Opera- m.ar de “todas” las especialidades. Escalabilidad: implemen- ble sobre permite implementaciones parciales o totales tación Windows y (desde un consultorio aislado hasta “toda una completa. Linux. HL7 provincia o un país”). Adicional: Máximo Compatible Control:, producto de tablero de comando integral en salud. http://www.biocom.com Bio- Sist. Preparado para firma digital. Orienta- Múltiples Con- Versión web com modular Español, inglés, francés do prin- módulos sultar enabled y integrado Interoperabilidad: HL7, ICD10, LOINC, cipal- avanzados. cliente servi- p/ presta- DICOM, ATM mente a dor. Instala- dores de servicios Argenti- do en insti- de salud na tuciones de Bs.As. http://www.erabt.com.a Medi- Solución Sistemas Integrados de Administración Siste- Argentin Máxima Consul Instalado en r base HIS Hospitalaria . ma a usabilidad, tar. obras (Hospital Sistemas de admisión de pacientes, de basado desde sociales y Informati cuidados a pacientes, para servicios de en punto de clínicas de on diagnósticos y tratamientos produc- vista de BsAs. System) Sistemas de Recursos Materiales, de Recur- tos de distinto tipo sos Humanos, de Facturación, de Administra- código de usua- ción y Finanzas, de Control de Gestión (Busi- abierto, rios. ness Intelligence). multi- Estructura de datos preparada para expan- plataf- INFOLAC2008 - AAIM © 2008 - Todos los derechos reservados sión, interoperabilidad, modularización, firma forma, digital, optimización. PACS C#, .Net, . http://www.historialglob Mi histo- Permite controlar su estado de Salud y cola- Orien- Usable Un pass- Gratui- Basado en la al.com.ar ria clínica borará con su médico personal en la preven- tado a vía Web word permi- to para Web. ción de enfermedades, anticipándole los con- uso por interna- te compartir pacien Prestaciones troles que debe hacer, de acuerdo a su edad, el cional, datos con tes, limitadas. sexo, trabajo, modo de vida y enfermedades.. mismo anónimo. el médico. pago Solventado pacien- Sencillo. para por Adsen- te. Ver- No valida institu- se. sión p/ fechas. No ciones. Esperando médi- tiene inter- Inter- email… cos e fase homo- nacio- instit. génea. nal http://www.costaisa.co Cos- CHAMA El Módulo Central está compuesto por la No deja m/defaultChaman.htm taisa N gestión de Pacientes, Episodios y Actuacio- mandar mail nes. Después están los módulos de Laborato- para pregun- rio, Vigilancia De La Salud, Quirófano, Urgen- tar precio. cias, Facturación, Consultas Externas, Hospi- talización http://www.medical- Medi- Hist. La HCA se articula con el Sistema de citas US$ Para hospi- co.info/ cal clin.auto médicas y con el sistema de Epidemiología 5000 tales Sys- matizada para la Dirección. Facilita la realización de <=10 tem estudios estadísticos, auditoría y auto- equi- evaluación. Contiene un kit “muy completo” pos.Int de herramientas y ayudas. ernac. http://www.care2x.org/ Care2x Multiplataforma. Requiere Apache 1.X , PHP esperando (4.0.4pl1 - 4.3.4), MySQL (3.2x - 4.0.x) email… http://www.biolinux.org. Bioli- OpenHIS OpenHIS es un desarrollo creado desde cero, HOME Español, Poco acti- GNU – ar nux con nuevo diseño. Significa Entorno Abierto Portu- vo? Open de
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