Odeibat Yousef M, Hiasat Mohammad Y, Ibrahim Bilal, Dabbas Waleed F, Alhazaimeh Mohammad H, Samara Qais A, Marji Ala, Alomari Amer A
Department of Neurological Surgery, Neuron Clinics, Amman, JOR.
Department of Neurological Surgery, Al-Balqa Applied University, Al-Salt, JOR.
Cureus. 2023 Sep 23;15(9):e45823. doi: 10.7759/cureus.45823. eCollection 2023 Sep.
Background The demanding nature of neurosurgical practice requires a reliable system for documentation and record-keeping. The cost of electronic health record systems can limit their availability in low- and middle-income countries. That is why less expensive and easily accessible technological alternatives should be sought. In this article, we describe our adopted system for medical record-keeping based on WhatsApp (Meta Platforms, Inc., Menlo Park, CA). Methods In our chain of six clinics, each clinic has its record-keeping WhatsApp group dedicated to sharing medical data of outpatients following up in that specific clinic and of inpatients cared for in hospitals in its area. After each encounter, our surgeons share smartphone-captured pictures of their patients' medical data on the WhatsApp group of the related clinic. The medical data are then categorized and stored by the secretary on the clinic's computer to be accessed at any time for record retrieval. Discussion Our five years of experience with the WhatsApp-based record-keeping system with medical records of 11,729 patients proved to be reliable, cost-effective, user-friendly, and efficient, and it positively impacted patient care. Responsible behavior, security precautions, and regulating policies are essential to protect patient confidentiality. Conclusion Our system can be an inexpensive alternative to the electronic health record system in small healthcare facilities. It can help physicians practicing in low- and middle-income countries to improve medical records documentation, thereby improving patient care. There is a need for policies to regulate the use of instant messaging applications in professional medical communication.
背景 神经外科手术的高要求性质需要一个可靠的文档记录和保存系统。电子健康记录系统的成本可能会限制其在低收入和中等收入国家的可用性。这就是为什么应该寻求更便宜且易于获取的技术替代方案。在本文中，我们描述了我们采用的基于WhatsApp（Meta平台公司，加利福尼亚州门洛帕克）的病历保存系统。方法 在我们的六家诊所连锁机构中，每家诊所都有其专门的病历保存WhatsApp群组，用于分享在该特定诊所接受随访的门诊患者以及在其所在地区医院接受治疗的住院患者的医疗数据。每次诊疗后，我们的外科医生会在相关诊所的WhatsApp群组中分享用智能手机拍摄的患者医疗数据图片。然后，秘书会对医疗数据进行分类并存储在诊所的计算机上，以便随时访问以检索记录。讨论 我们使用基于WhatsApp的病历保存系统处理11,729名患者病历的五年经验证明，该系统可靠、经济高效、用户友好且高效，并且对患者护理产生了积极影响。负责任的行为、安全防范措施和监管政策对于保护患者隐私至关重要。结论 我们的系统可以成为小型医疗机构中电子健康记录系统的廉价替代方案。它可以帮助在低收入和中等收入国家执业的医生改善病历记录，从而提高患者护理水平。需要制定政策来规范即时通讯应用在专业医疗通信中的使用。
