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.
The Electronic Health Records (EHR) is a longitudinal electronic record of patient heath information generated by one or more encounters in any care delivery setting. The information included in the type of records can be progress notes, problems, medication, vital signs, medical history, laboratory data, radiology reports and much more. The usability of an EHR is crucial to achieve success, as well as guaranteeing a high level of safe and effective level of patient care system. Therefore, it is important for care providers to take steps to ensure that their EHR will be usable. Aiming to assess the usability of the EHR, a usability evaluation was performed. This paper describes how two usability evaluation methods (heuristic walkthrough and surveys) were used to evaluate its usability. With those evaluations, it was able to recognize the level of usability present in the EHR, along with the usability issues that can be disposed.
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