Laing G L, Bruce J L, Skinner D L, Allorto N L, Clarke D L, Aldous C
Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Post-Net Suite #156, Private Bag X918, Pietermanitzburg, 3200, South Africa,
World J Surg. 2014 Jun;38(6):1388-97. doi: 10.1007/s00268-013-2438-2.
The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS).
Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death).
A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high.
It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.
彼得马里茨堡市大都会创伤服务中心此前成功构建并实施了一个电子手术登记系统（ESR）。本研究报告了我们将这一概念扩展并发展为一个多功能混合电子病历（HEMR）系统的尝试，该系统用于三级外科服务。这个HEMR系统旨在融合ESR、电子病历（EMR）系统和临床决策支持系统（CDSS）的功能及优势。
获得了维护HEMR系统的正式伦理批准。采购了合适的软件来开展该项目。数据模型设计为关系数据库。在设计和构建过程完成后，HEMR文件在一个安全服务器上启动。这带来了访问安全和自动备份的好处。实施了一个系统的培训计划用于客户培训。数据采集工作被整合到临床工作流程中，在多个时间点进行。在入院、手术干预、内镜干预、不良事件（发病率）以及患者护理结束（出院、转院或死亡）时采集数据。
在HEMR系统实施3个月后进行了季度审核。提取并审核数据以评估其质量。系统中总共捕获了1114条患者记录。合规率在87% - 100%之间，客户满意度很高。
在发展中国家的外科服务中构建并实施一个独特、简单且具有成本效益的HEMR系统是可行的。这个信息系统的独特之处在于它将EMR系统的离散功能与ESR和CDSS相结合。我们识别出了一些潜在限制并制定了干预措施来改善它们。这个HEMR系统为持续的质量改进计划和临床研究提供了必要的平台。
