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Electronic medical documentation –
safety and progress
Michał Milczarek
ALAB laboratoria sp. z o.o.
ALAB Group
•
•
•
•
Network of medical laboratories
36 locations in Poland
Over 20 M results /yr
Partner Labor Dr. Limbach und Kollegen – Heidelberg
Germany one of the biggest network of medical
laboratories in Europe
• ISO 15189: first laboratory that have been approved
in Poland
• Innovations as priority for company
Electronic medical documentation
• Electronic medical documantation has bben
legalised since June 2007 according to law from
Dec. 2006
• Immediate decision on electronic signing results in
ALAB – following new function in IT, technical and
organisational procedures
• First document signed in ALAB in June 2007
Reasons of introduction electronic documents
• Time save for staff – more time for validation
• Faster delivery of results to patient (pacjenta)
• New channel of results distribution became
possible
Workflow in medical lab
Distribution to doctor
Doctor
Order
Result signed
Registration
and admission
Signature
Order recorded
Material sent to
machines
Validation
Assesment of result
Making
investigations
Tradional result
•
•
•
•
Electronic result
• Exists only in electronic form(.xml
Exists in real, paper form
and .pdf files)
Is signed on paper
• Signed with qualified signature
Only one original
(.sig file)
Must be physically delivered • Printout shows results but
to client
printout itself is not a document
• Delivered to client via net or on
phisical carriers or made available
in net
Electronic result in ALAB
• Each diagnost has a card for electronic signature issued by KIR
• Laboratory Information System has an integrated module for
signature
• LIS prepares.xml and .pdf files that are signed and stored in
system
• Verification possible by tools delivered by KIR
• Client has an access to result, he/she can also print result on
his/her own
• Printout is not a document – it shows only the content of
document
This comment
appears on
printout when
the file was
signed
New forms of results distribution
• For doctors (iCentrum, integration with
Hospital Information System) – doctor gets
result that is recognised by law, not just a look
into result
• For patients– via internet site (results online) i
and self-service terminal
iCentrum – access for doctors
• Doctor (client) gets an access to LIS and results
on his/her desktop/laptop
• Connection using Virtual Private Network
keycode 2048 bytes long
• Access only for won orders
• Passwords generated for each client
Patient – access via Internet
• When the material is taken from patient,
he/she gets a code, that enables him/her to
collect result from internet site or in selfservice terminal
• In order to collect a result a computer with
browser is needed
• The site on which the results are showed is
secured (https)
CSALAB
0614610480
Wyniki badan laboratoryjnych
Laboratoria Analiz Lekarskich - ALAB
00-739 Warszawa, ul. Stępińska 22/30
tel. +48 (22) 349 60 12, fax. +48 (22)349 60 99,
ul. Stępińska 19/25
tel. +48 (22) 318 63 77, fax. +48 (22) 318 63 01
e-mali: [email protected]
http://www.alablaboratoria.com.pl
Do zlecenia nr 1234
W laboratorium nr 63 z dnia 12-05-2011
Data wykonania badania: 12-05-2011
Zlecił Brak Mozliwości Identyfikacji Lekarza
Serwis ALAB
PESEL:
21251572317
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Kabacki Leopold
Hematologia
Nazwa badania
Wynik badania
Zakres referencyjny
Materiał: Krew EDTA, pobrany: 7:00 (piel. Krystyna Babacka), przyjęty: 7:45
A1
Morfologia
WBC
❖ NEUT
❖ NEUT%
❖ LYM
❖ LYM%
❖ MONO
❖ MONO%
❖ EOS
❖ EOS%
❖ BASO
❖ BASO%
❖ LUC
❖ LUC%
RBC
HGB
HCT
MCV
MCH
CH
MCHC
RDW
HDW
PLT
MPV
PCT
PDW
A1
-
Odczyn Biernackiego
10,0
2,0
35,0
1,0
15,0
0,5
2,0
0,5
3,0
0,1
0,5
0,3
3,0
K/µL
K/µl
%
K/µl
%
K/µl
%
K/µl
%
K/µl
%
K/µl
%
9,0 — 30,0
1,8 — 7,7
33,0 — 70,0
0,6 — 4,1
10,0 — 35,0
0,0 — 0,8
1,0 — 10,0
0,0 — 0,8
1,0 — 4,0
0,0 — 0,2
0,0 — 1,0
0,0 — 0,4
0,0 — 4,0
5,0
16,0
50,0
120,0
30,0
40,0
30,0
15,0
3,0
300,0
10,0
0,15
50,0
M/µL
g/dL
%
fL
pg
pg
g/dL
%
g/dL
K/µL
fL
%
%
4,0 — 6,6
14,5 — 22,5
45,0 — 67,0
95,0 — 121,0
27,0 — 34,0
28,0 — 36,0
29,0 — 37,0
11,0 — 18,0
2,2 — 3,2
250,0 — 450,0
7,0 — 10,6
0,12 — 0,36
47,7 — 59,3
5
mm/h
<8
Biochemia
Nazwa badania
Wynik badania
Zakres referencyjny
Materiał: Surowica, pobrany: 7:00 (piel. Krystyna Babacka), przyjęty: 7:45
A1
A1
A1
A1
Cholesterol całkowity w surowicy
Cholesterol HDL w surowicy
Triglicerydy w surowicy
Cholesterol LDL (wyliczany)
150
50
150
70
mg/dl
mg/dl
mg/dl
mg/dl
< 200
> 40
50 — 200
< 130
Stężenie cholesterolu LDL w surowicy wyliczane jest wg równania Friedewalda. Stężenie triglicerydów powyżej 350 mg/dl (3,95 mmol/l) uniemożliwia wyliczenie
cholesterolu LDL. Wskazane jest wówczas powtórzenie badania na czczo lub badanie cholesterolu LDL metodą bezpośrednią.
A1
Wskaźnik aterogenności
1,0
<5
Koagulologia
Nazwa badania
Wynik badania
Zakres referencyjny
Materiał: Osocze, pobrany: 7:00 (piel. Krystyna Babacka), przyjęty: 7:45
A1
A1
A1
Czas kaolinowo - kefalinowy (APTT)
Fibrynogen
Czas protrombinowy (PT) /wskaźnik Quicka, INR/
Wskaźnik protrombinowy
INR
Czas
30,0
sek
200,00 mg/dl
26,00 — 40,00
180,00 — 350,00
120,00 %
1,00
10,0
sek
70,00 — 130,00
0,85 — 1,15
WYNIK TESTOWY Wszystkie wartości są fikcyjne I zostały wprowadzone jedynie na potrzeby prezentacji
Wykonali
A - Hoffet Aleksandra
Zatwierdzili
1 - Hoffet Aleksandra
Dok. opatrzony podpisem elektronicznym weryfikowanym cert. kwalifikowanym - KIR s.a.
10217 Diagnosta laboratoryjny - Hoffet Aleksandra
Środowisko Centrum - © MARCEL Sp. z o. o.
12-05-2011 08:42, strona 1/1
Self-service terminal
• Located near to
collection point
• 24/7 on duty
• Result can be collected
using code that is
handed out on colletion
time
Results of changes
• Diagnost makes a work, for which was trained,
not doing stamping
• Doctor, client gets result witout delay, just on
time when the result is signed, diagnost takes
full responsability for the result
• Patiant has an access to results, no risk of lost
results
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