A carregar...
Publicação
Registos eletrónicos médicos nos cuidados de saúde primários : uma revisão narrativa holística
| Nome: | Descrição: | Tamanho: | Formato: | |
|---|---|---|---|---|
| 1.36 MB | Adobe PDF |
Autores
Orientador(es)
Resumo(s)
A utilização dos sistemas informáticos em saúde é atualmente uma realidade incontornável da prática clínica. Por serem instrumentos centrais no trabalho do profissional de saúde, estes podem ter um impacto importante no seu método de trabalho e ultimamente na qualidade de cuidados providenciado aos doentes. O presente trabalho propõe-se a realizar uma revisão narrativa holística do tema, explorando todas as principais áreas que os Registos Eletrónicos Médicos (EMR) envolvem, e descrevendo mais detalhadamente a realidade destes sistemas na Medicina Geral e Familiar. Foi feita uma pesquisa da literatura com dois braços temáticos, um referente à usabilidade destes sistemas e outro referente à sua utilização em contextos de Medicina Geral e Familiar. Desta pesquisa foram selecionados 37 artigos para o primeiro braço temático e mais 47 para o segundo. Através da análise da literatura dividiu-se a discussão do tema em causas e consequências das problemáticas relacionadas com os EMR. Relativamente às consequências, abordou-se temas como o burnout associado ao uso de EMR, a comunicação intra e inter-instituicional, a influência dos EMR na qualidade de registos e outcomes clínicos e também o impacto na relação médico-doente e dinâmica da consulta em Medicina Geral e Familiar. Das causas discutiu-se dois grades temas, o design dos EMR e a implementação e manutenção do uso destes sistemas. Como principais conclusões destacam-se a necessidade de apostar na interoperabilidade de sistemas, a recomendação de obrigatoriedade de certificação destes sistemas, a importância de ter planos de implementação e manutenção adequados ao contexto da instituição alvo, apostando em treino e apoio técnico adequados, e também a criação de EMR’s que possam ser customizados às necessidades da instituição e personalizados às necessidades individuais do médico. Por fim, a principal recomendação feita é que se promova um maior envolvimento da comunidade médica na criação e implementação destes sistemas.
The use of informatic systems in health is nowadays something unavoidable. Because they are central to the work of health professionals they have the potential of being extremely impactful in the way medical staff work as well as influencing the quality of medical records and of medical care. This work’s goal is to allow for a holistic narrative review of the main areas related to the use of Electronic Medical Records (EMR) and also discuss, more in depth, about its use in Primary Care. The literature search for this review was made using two different lines of search thematics. One was about the usability of EMR and another was about the use of EMR in Primary Care. For the first line of search 37 articles where selected, and 47 where selected for the second one. Based on the literature review, multiple themes emerged which where divided into causes and consequences of the use of the EMR. In the consequences part, the main themes discussed where the burnout associated with the use of EMR, the communication inside health centers and between health centers, the impact of EMR in health records and medical outcomes and also in the patient-doctor relationship and the doctor’s consultation dynamics. In the causes section, two main themes where discussed, the design of EMR’s and the implementation and meaningful use of EMR’s. As the main conclusions of this review, there is the need for improving interoperability between systems, the recommendation of mandatory certification processes of EMR based on the current literature, the importance of implementation and meaningful use programs that are adequate to the institutions organization a medical context and focus on adequate training and technical support. There is also the recommendation of designing EMR’s that can be customized for the health institution needs and also personalized for each doctor preferences. At last, the most important recommendation of this work is the need for more involvement of the medical community in the development of EMR design as well as in the implementation and meaningful use programs.
The use of informatic systems in health is nowadays something unavoidable. Because they are central to the work of health professionals they have the potential of being extremely impactful in the way medical staff work as well as influencing the quality of medical records and of medical care. This work’s goal is to allow for a holistic narrative review of the main areas related to the use of Electronic Medical Records (EMR) and also discuss, more in depth, about its use in Primary Care. The literature search for this review was made using two different lines of search thematics. One was about the usability of EMR and another was about the use of EMR in Primary Care. For the first line of search 37 articles where selected, and 47 where selected for the second one. Based on the literature review, multiple themes emerged which where divided into causes and consequences of the use of the EMR. In the consequences part, the main themes discussed where the burnout associated with the use of EMR, the communication inside health centers and between health centers, the impact of EMR in health records and medical outcomes and also in the patient-doctor relationship and the doctor’s consultation dynamics. In the causes section, two main themes where discussed, the design of EMR’s and the implementation and meaningful use of EMR’s. As the main conclusions of this review, there is the need for improving interoperability between systems, the recommendation of mandatory certification processes of EMR based on the current literature, the importance of implementation and meaningful use programs that are adequate to the institutions organization a medical context and focus on adequate training and technical support. There is also the recommendation of designing EMR’s that can be customized for the health institution needs and also personalized for each doctor preferences. At last, the most important recommendation of this work is the need for more involvement of the medical community in the development of EMR design as well as in the implementation and meaningful use programs.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Palavras-chave
Registos médicos eletrónicos Usabilidade Design Implementação Medicina geral e familiar