AUTHORS
Álvaro Solaz-García
María Dolores Blaya-Nicolás
Iván Montoya-Carrillo
María José Puig-Sánchez
Alba Simeón-Moragón
Ana María Regueira-Artero
KEY WORDS
Information systems, electronic health records, operating theatres, Extracorporeal Circulation.
ABSTRACT
Introduction. The integration of health information systems has transformed the management of and access to medical records. Electronic health records (EHRs) play a major role in this process. In the surgical area, electronic records improve efficiency, safety, quality of care and allow for the secondary use of data for research. These systems have to centralise data, be secure, allow for the integration of medical teams, interoperate with other systems, and provide support for decision-making, adapting to clinical and technological advances.
Goal. The goal of this study is to design and implement an integrated electronic information system for the perfusion and extracorporeal oxygenation nursing department at La Fe Hospital.
Material and Method: There were several different phases in the development of the system: conceptual design, analysis of paper systems, the review of variables and data, design of the electronic register, prototyping, the evaluation of connections and interoperability, the validation of the prototype and implementation.
Results. Printed records and variables from haemodynamic, respiratory and monitoring support devices were thoroughly reviewed. This data was digitised and a prototype EHR was created using Philips ICCA software. The system includes a pre-operative checklist, perfusion report, automated monitoring chart, and records of drug administration and surgical times. It is integrated with the hospital’s EHR, improving management, optimising resources, increasing patient safety and facilitating decision making. The unification of records allows for secondary use in research.
Conclusions. The implementation of the electronic record in the perfusion and extracorporeal oxygenation nursing department has improved decision-making, resource management, patient safety and quality of care. In addition, it facilitates the evaluation of indicators and ongoing improvement, allowing for the use of unified data in research.