Electronic medical documentation safety and progress

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Iwona Nowak
8 lat temu
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1 Electronic medical documentation safety and progress Michał Milczarek ALAB laboratoria sp. z o.o.

2 ALAB Group Network of medical laboratories 36 locations in Poland Over 20 M results /yr Partner Labor Dr. Limbach und Kollegen Heidelberg Germany one of the biggest network of medical laboratories in Europe ISO 15189: first laboratory that have been approved in Poland Innovations as priority for company

3 Electronic medical documentation Electronic medical documantation has bben legalised since June 2007 according to law from Dec Immediate decision on electronic signing results in ALAB following new function in IT, technical and organisational procedures First document signed in ALAB in June 2007

4 Reasons of introduction electronic documents Time save for staff more time for validation Faster delivery of results to patient (pacjenta) New channel of results distribution became possible

5 Workflow in medical lab Distribution to doctor Doctor Order Result signed Registration and admission Signature Validation Making investigations Order recorded Material sent to machines Assesment of result

6 Tradional result Exists in real, paper form Is signed on paper Only one original Must be physically delivered to client Electronic result Exists only in electronic form(.xml and.pdf files) Signed with qualified signature (.sig file) Printout shows results but printout itself is not a document Delivered to client via net or on phisical carriers or made available in net

7 Electronic result in ALAB Each diagnost has a card for electronic signature issued by KIR Laboratory Information System has an integrated module for signature LIS prepares.xml and.pdf files that are signed and stored in system Verification possible by tools delivered by KIR Client has an access to result, he/she can also print result on his/her own Printout is not a document it shows only the content of document

8 This comment appears on printout when the file was signed

9 New forms of results distribution For doctors (icentrum, integration with Hospital Information System) doctor gets result that is recognised by law, not just a look into result For patients via internet site (results online) i and self-service terminal

10 icentrum access for doctors Doctor (client) gets an access to LIS and results on his/her desktop/laptop Connection using Virtual Private Network keycode 2048 bytes long Access only for won orders Passwords generated for each client

12 Patient access via Internet When the material is taken from patient, he/she gets a code, that enables him/her to collect result from internet site or in selfservice terminal In order to collect a result a computer with browser is needed The site on which the results are showed is secured (https)

16 Środowisko Centrum - MARCEL Sp. z o. o :42, strona 1/1 Laboratoria Analiz Lekarskich - ALAB Warszawa, ul. Stępińska 22/30 tel. +48 (22) , fax. +48 (22) , ul. Stępińska 19/25 tel. +48 (22) , fax. +48 (22) e-mali: labowars@alab.com.pl Kabacki Leopold CSALAB Wyniki badan laboratoryjnych Do zlecenia nr 1234 W laboratorium nr 63 z dnia Data wykonania badania: Zlecił Brak Mozliwości Identyfikacji Lekarza Serwis ALAB PESEL: mężczyznaur Hematologia Nazwa badania Wynik badania Zakres referencyjny Materiał: Krew EDTA, pobrany: 7:00 (piel. Krystyna Babacka), przyjęty: 7:45 Morfologia WBC 10,0 K/µL 9,0 30,0 NEUT 2,0 K/µl 1,8 7,7 NEUT% 35,0 % 33,0 70,0 LYM 1,0 K/µl 0,6 4,1 LYM% 15,0 % 10,0 35,0 MONO 0,5 K/µl 0,0 0,8 MONO% 2,0 % 1,0 10,0 EOS 0,5 K/µl 0,0 0,8 EOS% 3,0 % 1,0 4,0 BASO 0,1 K/µl 0,0 0,2 BASO% 0,5 % 0,0 1,0 LUC 0,3 K/µl 0,0 0,4 LUC% 3,0 % 0,0 4,0 RBC 5,0 M/µL 4,0 6,6 HGB 16,0 g/dl 14,5 22,5 HCT 50,0 % 45,0 67,0 MCV 120,0 fl 95,0 121,0 MCH 30,0 pg 27,0 34,0 CH 40,0 pg 28,0 36,0 MCHC 30,0 g/dl 29,0 37,0 RDW 15,0 % 11,0 18,0 HDW 3,0 g/dl 2,2 3,2 PLT 300,0 K/µL 250,0 450,0 MPV 10,0 fl 7,0 10,6 PCT 0,15 % 0,12 0,36 PDW 50,0 % 47,7 59,3 Odczyn Biernackiego 5 mm/h < 8 Biochemia Nazwa badania Wynik badania Zakres referencyjny Materiał: Surowica, pobrany: 7:00 (piel. Krystyna Babacka), przyjęty: 7:45 Cholesterol całkowity w surowicy 150 mg/dl < 200 Cholesterol HDL w surowicy 50 mg/dl > 40 Triglicerydy w surowicy 150 mg/dl Cholesterol LDL (wyliczany) 70 mg/dl < 130 Stężenie cholesterolu LDL w surowicy wyliczane jest wg równania Friedewalda. Stężenie triglicerydów powyżej 350 mg/dl (3,95 mmol/l) uniemożliwia wyliczenie cholesterolu LDL. Wskazane jest wówczas powtórzenie badania na czczo lub badanie cholesterolu LDL metodą bezpośrednią. Wskaźnik aterogenności 1,0 < 5 Koagulologia Nazwa badania Wynik badania Zakres referencyjny Materiał: Osocze, pobrany: 7:00 (piel. Krystyna Babacka), przyjęty: 7:45 Czas kaolinowo - kefalinowy (APTT) 30,0 sek 26,00 40,00 Fibrynogen 200,00 mg/dl 180,00 350,00 Czas protrombinowy (PT) /wskaźnik Quicka, INR/ Wskaźnik protrombinowy 120,00 % 70,00 130,00 INR 1,00 0,85 1,15 Czas 10,0 sek WYNIK TESTOWY Wszystkie wartości są fikcyjne I zostały wprowadzone jedynie na potrzeby prezentacji Wykonali A - Hoffet Aleksandra Zatwierdzili 1 - Hoffet Aleksandra Dok. opatrzony podpisem elektronicznym weryfikowanym cert. kwalifikowanym - KIR s.a Diagnosta laboratoryjny - Hoffet Aleksandra

17 Self-service terminal Located near to collection point 24/7 on duty Result can be collected using code that is handed out on colletion time

18 Results of changes Diagnost makes a work, for which was trained, not doing stamping Doctor, client gets result witout delay, just on time when the result is signed, diagnost takes full responsability for the result Patiant has an access to results, no risk of lost results

19 Dziękuję za uwagę

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