CONCEPT OF MODERN CLINICAL INFORMATION SYSTEM

Mnogo procesnih slabosti pri kliničnem in administracijskem delu zdravnikov v bolnišnicah je predvsem posledica pomakljive standardizacije in optimizacije diagnostičnih, terapevtskih in drugih postopkov v bolnišnicah. Veliko pomanjkljivosti ima skupni imenovalec v ogromnih količinah papirnatih in nesistematiziranih podatkih, česar jedro v vsakodnevni praksi predstavljajo temperaturno-terapevtski listi (TTL) bolnikov. Ti so namreč leglo nesporazumov, napak in velikih stroškovnih posledic. Tradicionalni papirnati klinični sistemi ne zadovoljujejo več potreb informacijske družbe, zato jih je potrebno nadgraditi oz. zamnjeti z modernimi kliničnimi informacijskimi sistemi. Uvedba digitalnega temperaturno-terapevtskega lista (dTTL) v splošnem prinaša: transparentnost medicinske oskrbe in s tem večjo varnost za bolnika, višjo učinkovitost dela v bolnišnici, lažje ter preglednejše vodenje podatkov v procesih zdravljenja in oskrbe ter ne nazadnje tudi znižanje skupnih stroškov. Osnovna ideja kocenpta je v zamenjavi obsotoječega temperaturnega lista v bolnišnicah z novimi, digitalnimi - ob podpori računalniških sistemov. Zdravnik mora informacijsko tehnologijo uporabljati ob fizični prisotnosti bolnika, saj je to edini način res učinkovitega zdravljenja. Programsko je potrebno integrirati že obstoječe podatkovne baze, kot so mednarodna klasifikacija bolezni, register zdravil in druge ter jih med seboj tudi povezati.Many processing difficulties in clinical and administrative work of physicians in hospitals are mainly a result of insufficient standardization and optimization of diagnostic, therapeutic and other procedures in hospitals. A lot of the weaknesses can be derived to a common denominator: a vast amount of paper and non-systemised data that in everyday routine mainly consists of patients’s charts. These are at the core of most misunderstandings, mistakes and resulting high costs. Because the traditional paper-based clinical systems fail to fulfil the expectations of today’s information society, it has to be upgraded or rather exchanged with modern clinical information systems. The introduction of the digital patient’s charts means in general: a more transparent medical care and consequently greater security for the patient, higher efficiency of work in hospitals, easier and more convenient data management in processes of treating a patient and last but not least the reduction of overall expanses. The main idea behind the concept is the exchange of the existing patient’s chart in hospitals with the new, digitalised one – with the help of computer systems. The physician has to use the information technology while the patient is present. This is the only way of making medical care truly efficient. In regard of software, the existing databases like the International Classification of Diseases and the register of medicinal products have to be integrated and also connected