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Bulletin of the Croatian Society for Medical Informatics (Online), Vol. 27 No. 1, 2021.

Professional paper

Guidelines for the Advancement of Electronic Health Records

Josipa Kern orcid id orcid.org/0000-0002-0896-3018 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; University of Zagreb, School of Medicine, Zagreb, Croatia
Biserka Bergman Marković orcid id orcid.org/0000-0002-3657-4001 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; University of Zagreb, School of Medicine, Zagreb, Croatia
Predrag Pale orcid id orcid.org/0000-0003-2171-7302 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; University of Zagreb, Faculty of Electrical Engineering and Computing, Zagreb, Croatia
Inge Heim orcid id orcid.org/0000-0003-4535-2512 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb, Croatia
Božica Trnka orcid id orcid.org/0000-0003-2135-7749 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb, Croatia
Goranka Rafaj orcid id orcid.org/0000-0001-9878-3901 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; Technical College Bjelovar, Study in Nursing, Bjelovar, Croatia
Karmen Lončarek orcid id orcid.org/0000-0003-2481-5098 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; University of Rijeka, Faculty of Medicine, Rijeka, Croatia
Kristina Fišter orcid id orcid.org/0000-0002-5160-4694 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; University of Zagreb, School of Medicine, Zagreb, Croatia
Miroslav Mađarić orcid id orcid.org/0000-0001-7386-8888 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb, Croatia
Đuro Deželić orcid id orcid.org/0000-0002-7315-9317 ; Committee for eHealth, Croatian Academy of Medical Sciences; University of Zagreb, School of Medicine, Zagreb, Croatia
Vesna Ilakovac ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia
Marijan Erceg orcid id orcid.org/0000-0002-7720-9422 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; Croatian Institute of Public Health, Zagreb, Croatia
Ivan Pristaš orcid id orcid.org/0000-0002-6732-7943 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; Croatian Institute of Public Health, Zagreb, Croatia
Anamarija Margan Šulc orcid id orcid.org/0000-0002-5174-5921 ; Committee for eHealth, Croatian Academy of Medical Sciences, Zagreb; Internal Medicine Clinic, Mali Lošinj, Croatia
Silvije Vuletić orcid id orcid.org/0000-0002-0620-8107 ; Committee for eHealth, Croatian Academy of Medical Sciences; University of Zagreb, School of Medicine, Zagreb, Croatia

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Abstract

The Guidelines have been proposed for the development of electronic health records (EHR) that must meet the needs of all relevant stakeholders. The system of electronic health records should contribute to the improvement of health services to healthcare users, support the daily work of health professionals and enable continuous improvement of quality at all levels of the health care system. The following concepts are defined: electronic health record, electronic medical record (EMR) and electronic personal health record (EpHR); Any health care user should have one EHR, one EpHR, and multiple EMRs. The parts of the EHR, i.e., the EMR and EpHR, should not be physically kept in the same place, but must be interconnected in case of need (via the health care user unique identification and authentication rules). All EMRs contain data collected by health professionals in health facilities (primary health care, polyclinics, hospitals, public health institutes, etc.). This data can be entered directly or transmitted from medical devices. The EpHR contains data collected and maintained by the health care user. They can be recorded directly or transmitted from a medical device. Data in the EHR may be made available to authorized persons only. Data protection in the EHR should be ensured in three ways: technically, regulatory and through codes of ethics, in line with international initiatives (certification, EU regulations, standards, etc.). The EHR and its components should be used for both primary and secondary purposes. The primary use of the data relates to the individual (diagnosis, therapy, vaccination, etc.). The secondary use relates to population groups (reporting on the health status of the population, the quality of health care, the effects of preventive activities, funding, and research, etc.). The EHR data (structured or not) should be defined by health care professional associations. The ICT experts need to offer optimal technological solutions. The EHR development strategy, as well as supervision (medical, legal, technical, and ethical aspects, as well as standardization) should be entrusted to the institution at the national level, i.e., the Central eHealth Authority. EHR (EMR and EpHR) should be developed in stages, step by step, depending on current knowledge, technology, and material resources.

Keywords

electronic health record; electronic medical record; electronic personal health record; primary/secondary use of data

Hrčak ID:

253270

URI

https://hrcak.srce.hr/253270

Publication date:

28.2.2021.

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