Isaac Azancot : "Structuring information in the patient file"

The imminent implementation and gradual deployment of the electronic health record (DMP) throws up some key questions around the computerization of patient files in health institutions and the structuring and standardization of medical data before information is exchanged and fed into health networks. And yet, alarmingly, fewer than 10% of French health institutions of all sizes currently have the capability to adequately feed information into the DMP, which justifies the efforts made by ASIP to quickly promote a "healthcare office software" plan.

How, in health institutions, do we reconcile the precision and specificity of the information, and the ergonomic and informative nature of a medical report, with standardization, which involves structuring the file and employing semantics that enable the data to be exchanged and used? How do we ensure that healthcare stakeholders use the IT tool provided to them in every area?

• Providing administrative staff with an advanced office tool, using dictation and digital recognition technologies which enable medical metadata to be deployed rapidly with "minimum structuring"; data to be fed into a secure Web portal for viewing information; data to be fed into the DMP; and doctors working within and outside hospitals to communicate via an integrated secure messaging service. 
• Creating "structured technical files" (STFs) with information gathered from different sources: these are adaptable, user-friendly forms that enable all departments to define their own STFs according to their needs, or enable an institution to define STFs that contain common minimum fields which can then be filled in according to the specific needs of the users. This tool – which does not require any knowledge of programming – includes features for sharing fields or categories of field among several STFs, and is based on medical frameworks (most notably CIM10, CCAM and SNOMED) and on a library for sharing nomenclatures and concepts; it also complies with the CDA interoperability standards laid down by ASIP and has an integrated statistical request extraction function.
• Convergence of the different STFs constituted in this way towards "clinical structured files" (CSFs) which manage hospitalizations and consultations and are automatically updated during the patient's clinical circuit around the health institution by means of adaptable summaries taken from the STFs or by means of documents or images derived from the various methods. This way of organizing the sharing of information minimizes redundant entries and largely explains why the tool has been so widely used (all the departments involved in producing the site are connected, over 150 structured files have been deployed, and over 1,000 documents and films are added to the secure intranet portal every day).