Marimon-Suñol Santiago, Rovira-Barberà María, Acedo-Anta Mateo, Nozal-Baldajos Montserrat A, Guanyabens-Calvet Joan
Departament de Salut, Generalitat de Catalunya, Barcelona, España.
Med Clin (Barc). 2010 Feb;134 Suppl 1:45-8. doi: 10.1016/S0025-7753(10)70009-9.
Under the law adopted by its Parliament, the Government of Catalonia has developed an electronic medical record system for its National Health System (NHS). The model is governed by the following principles: 1) The citizen as owner of the data: direct access to his data and right to exercise his opposition's privileges; 2) Generate confidence in the system: security and confidentiality strength; 3) Shared model of information management: publishing system and access to organized and structured information, keeping in mind that the NHS of Catalonia is formally an "Integrated system of healthcare public use" (catalan acronym: SISCAT) with a wide variety of legal structures within its healthcare institutions; 4) Use of communication standards and catalogs as a need for technological and functional integration. In summary: single system of medical records shared between different actors, using interoperability tools and whose development is according to the legislation applicable in Catalonia and within its healthcare system. The result has been the establishment of a set of components and relation rules among which we highlight the following: 1) Display of information that collects sociodemographic data of the citizen, documents or reports (radiology, laboratory, therapeutic procedures, hospital release, emergency room), diagnostic health, prescription and immunization plus a summary screen with the most recent and relevant references; 2) Set of tools helping the user and direct messaging between professionals to facilitate their cooperation; 3) Model designed for supranational connections which will allow adding later, with ad hoc rules, clinical data provided by the private health sector or the proper citizen.
根据加泰罗尼亚议会通过的法律,加泰罗尼亚政府为其国家卫生系统(NHS)开发了一个电子病历系统。该模式遵循以下原则:1)公民作为数据所有者:可直接访问其数据并有权行使反对特权;2)建立对系统的信任:具备强大的安全性和保密性;3)信息管理的共享模式:发布系统并提供对有组织和结构化信息的访问,要知道加泰罗尼亚的国家卫生系统正式是一个“公共医疗综合系统”(加泰罗尼亚语缩写:SISCAT),其医疗机构内有多种法律结构;4)根据技术和功能整合的需要使用通信标准和目录。总之:不同行为者之间共享单一的病历系统,使用互操作性工具,其开发符合加泰罗尼亚适用的法律及其医疗系统。结果是建立了一组组件和关系规则,其中我们突出以下几点:1)显示收集公民社会人口数据、文件或报告(放射学、实验室、治疗程序、出院、急诊室)、健康诊断、处方和免疫接种的信息,以及一个包含最新和相关参考资料的摘要屏幕;2)一组帮助用户的工具以及专业人员之间的直接消息传递,以促进他们的合作;3)为超国家连接设计的模式,这将允许以后根据特定规则添加由私营卫生部门或公民本人提供的临床数据。