Model of Electronic Health Record for Gynecology Practice in Bulgaria

Abstract

The Health Information Management Systems Society’s (HIMSS) definition of EHRs is: “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician's work flow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”
It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office. An EHR is not a longitudinal record of all care provided to the patient in all venues over time.
This paper presents a functional software development, specialized for obstetrics and gynecology practice in Bulgarian medical environment. The record design is subordinated to the Bulgarian and international medical laws for tracing the pregnancy period. It consists of three separated modules – medical history of the patient, administrative data, tracing the pregnancy in 3 trimesters with various tests and medical analyzes, different for each trimester. It allows multimedia history archive, heart rate records, 3D/4D video records, fetal morphology history, biochemical screening record, weekly echograph records and full laboratory history at simple screen.
It performs telemedical functions through the possibility to connect from every point with Internet and to be accessible both – for patient and doctor.
The EHR is unique for Bulgarian gynecology medical practice. It combines the validate paper version of pregnant patient record with separate medical exams that are performed from different specialists and genetic laboratories.