Electronic medical files for patients: some steps towards the future

Abstract

There are records of footprints made by hominids in Tanzania 3.6 million years ago. By around 300,000 years ago, the human brain had doubled in size and acquired biological characteristics such as the ability to speak, which placed mankind in a prominent position among terrestrial beings. Speech, along with communication as a whole, has probably been one of mankind's greatest inventions.1 Medical files are known by the term prontuário in Portuguese, which comes from the Latin promptuarium, meaning a place where things that might be needed at any moment are kept. Medical files for possible immediate use are documents as old as the history of medicine itself and the first such documents were produced by the Egyptian physician Inhotep (around 3,000 to 2,500 BC). 2Modern man has tools at his disposal for storing and organizing information and making it available. The growth of information and its complexity rapidly lead to a situation of constant challenge in which time is the implacable enemy. At the touch of a few buttons, we can have new information and communication technology at our fingertips, along with electronic support for accessing data on any given subject almost instantaneously. Electronic medical files for patients are no exception and have been shown to be a great challenge in any part of the modern world, forming part of a project that is as necessary as it is intangible, in its broadest conception. While we can imagine the possibility of having all the medical information, or an even more holistic form of information, on any individual's health, at the disposal of physicians and other health promoters at any time and in any place, we can also perceive that such opportunities rarely translate into real options because of the various difficulties relating to their implementation.An article recently published in the New England Journal of Medicine 3 classified electronic medical files into three categories or systems: basic, without clinical annotations; basic, with clinical annotations; and advanced, in an integrated manner. According to a questionnaire answered by 3,049 institutions in the United States, the rates of implementation of these systems were 10.9%, 7.6% and 1.5%, respectively. It is of interest to highlight that, in this survey, the great majority of the physicians believed that electronic medical files would be of great value for patient care. It can thus be gathered that although this would be a very welcome tool, there is great difficulty in putting it into practice.On the other hand, it has already been demonstrated that many of the systems and functional features required for establishing true electronic medical files are already in place and in use in many healthcare units, albeit without any interaction between them.3 The greatest difficulties in implementing an integrated system are: lack of capital to acquire such a system; maintenance costs; resistance among physicians; rate of return for a doubtful investment; and insufficiencies in the information technology (IT) team.3 Resist...

Completude das informações do registro hospitalar de câncer em um hospital de Florianópolis

“…Nesse sentido, a melhoria da qualidade do registro em saúde, mediante o incentivo à estruturação da chamada "informática médica", com fichas eletrônicas padronizadas provendo campos obrigatórios que facilitem a coleta de informações essenciais aos serviços de saúde, tem como finalidade aperfeiçoar o armazenamento, a recuperação e o gerenciamento dessas informações 19,30,31 . Estudos pontuam que a aplicação de protocolos eletrônicos ainda é limitada devido aos custos dos equipamentos para implementação e manutenção, à falta de mão de obra qualificada e à possível resistência dos profissionais ao uso da informática 27,32 . No entanto, espera-se que com a realidade virtual atual, seja possível o desenvolvimento de um protocolo eletrônico com baixo custo, pouco espaço físico e mínimo treinamento de recursos humanos 27 .…”

“…Portanto, o adequado controle do câncer requer a utilização de recursos diagnósticos, terapêuticos e de informação cada vez mais complexos 32 , sendo imprescindível a busca por informações precisas e de qualidade para que a implementação de políticas pú-blicas leve à realização de ações efetivas na população alvo, contribuindo para a melhora do cenário atual, tanto no diagnóstico precoce e prognóstico favorável das neoplasias, quanto na minimização das sequelas decorrentes do tratamento e na oferta de atendimentos da equipe multiprofissional.…”