Requirements of the IT system in which medical records are kept
A number of possibilities and facilities offered by a modern IT system in medical documentation, related to
it is also with the specific requirements according to which such a database can be implemented. Thanks to EDM, access to
patient data are available to both doctors and authorized employees who register them for visits,
examinations, as well as sharing their medical records. However, so that there is no breach of personal data
customers of offices, hospitals or clinics, you should implement one consistent and compliant IT system that
will allow easy and, most importantly, safe use of the archive.
What is Electronic Medical Records (EDM)?
This concept was introduced together with the Act of 28 April 2011 on the information system in health care, which
obliges all institutions working under the National Health Fund and private practices to implement EDM. This system
is therefore a collection of various types of medical documents: kept, stored, secured and
provided by each facility that provides health services. The archive will contain data and statements
the patient, descriptions of his health, descriptions of health services provided to him, history of diseases, visits,
as well as the medications you are taking. It is therefore a kind of specialized patient card that contains his entire history
diseases, consents, stays in centers and prescriptions issued by all specialists who provided him / her
medical assistance. Therefore, it is required that the information system is both easy to use but also appropriate
secures sensitive data.
Requirements of an IT system with medical records
The implementation of the EDM system is related to the fulfillment of the requirements specified in the act, which guarantee effective
and lawful activities of personnel in the field of conducting, storing, securing and sharing
data of patients using the health services of a given facility. The implemented IT system must
provide a series of possibilities that will ensure effective and safe work with data. The most important feature of electronic
the integrity of medical records. It consists in securing the documentation and metadata against
introducing changes (except for changes introduced on the basis of implemented procedures). Another factor what
EDM must be met by its permanent access for users (authorized persons, e.g. facility staff). EDM requires
also effective protection against unauthorized access, which in turn is related to the possibility
identifying the person who makes any changes to the medical records or metadata. Any modification
it must therefore bear the identification data of the person making it, but also contain the exact time
the changes made. Additionally, each entry requires the signature of the person implementing it. That is, to be implemented
IT system of EDM, the selected software must provide the possibility of signing.
Additional functions, and at the same time the requirements of electronic medical documentation, also include: possibility
keeping and sharing data in formats and standards issued on the basis of Article 11 (1a) and (1b) of 28
April 2011, possibility of printing documentation, possibility of exporting all data in the indicated formats
and standards (eg XML, SQL), in a way that can be recreated in another ICT system, possibility
generating the so-called collective medical records.
Preparation for EDM implementation
An institution that is preparing to introduce EDM must meet the appropriate requirements to be able to provide
their patients an efficient and safe medical service. One of the most important criteria from which it will be
appropriate functionality of the IT system was important to ensure the appropriate infrastructure in the office
medical, as well as the choice of software compatible with all devices necessary for work. Required
is that the selected IT software should be transparent, intuitive and automatically updated. Before
the introduction of the selected software is also required to reserve an appropriate amount of time for
training of all staff. It may be necessary to contact the IT specialists responsible for the installation
software – thanks to their help, staff will learn its functions, operation and operation easier and faster.
