Prontuário eletrônico do paciente: padronização e interoperabilidade

Abstract

We present the results of research that sought to answer the question: What is the understanding that Information and Communication Technology professionals working in health organizations have on interoperability standards and their applicability in these organizations and in the context the Electronic Patient Record? Aiming to characterize the ICT professionals working in health organizations; measure the level of knowledge that they have about standards in general and for health, the understanding of the syntactic and semantic interoperabilities, as well as the Ordinance No. 2073/11; as well as draw a parallel with the practical use of such standards. Exploratory research with quantitative, qualitative approach and descriptive. The empirical study was carried out by the four health organizations located in the city of Marilia - São Paulo. Data collection was via online questionnaire - SurveyMonkey software, with open and closed questions about knowledge and the applicability of the standards of syntactic and semantic interoperabilities these organizations as well as the understanding regarding the legal aspects that protect data and patient information. The results show that knowledge of interoperability standards and their applicability to the context of information systems of healthcare organizations that include the patient's chart still are, in a way, elementary, for 70.59% they associated this concept to rules , models, regulations, protocols, standardization, but they do not know conceptualize what are interoperability standards. Apart from, 17.65% claimed to ignore this concept and 14 standards defined in Ordinance No. 2073 of the Ministry of Health, 31 August 2011, only the International Classification of Diseases, The table of the Unified Health System, Information Exchange in Health Supplementary and Unified Terminology for Supplementary Health were expressed by investigated. This result highlights the need to invest in the dissemination and training in the use of these pardons to better quality patient care.