Abstract
The medical record is the document that contains the details of a patient's clinical history. It represents a fundamental tool for patient treatment and care. In recent years, both in Italy and in other countries, several projects have promoted the use of computerized medical records; some of these projects have already been undertaken and concluded. An electronic medical record is easier to use than one that is paper-based, and it is more effective not only for patient treatment and care, but also for other purposes, uses and applications.
In fact, the electronic medical record can represent an effective tool for work, for management and for clinical governance, and not just a tool for storing information related to patient care. The collection of a patient's clinical and health information can indeed be relevant for care effectiveness, for monitoring the outcome of treatment and for future planning, both for health professionals and for the efficiency of internal organizational structures and in general for the Health Service.
The aim of this paper is to illustrate an experimental training model based on the use of electronic medical records. It will be tested in some wards at the University Hospital "P. Giaccone" in Palermo. We have developed a model of an electronic medical record that will be used both for the aims and objectives listed above, and as an effective method of training for health professionals in Continuing Medical Education.
In particular, we have developed a model of an integrated electronic medical record which allows different health professionals working in health care and involved at different levels in patient care and assistance, to learn on the job, in their own workplace, through the active and collaborative construction of knowledge and through the analysis of the clinical data registered in the electronic medical record system.
The model of an electronic medical record consists of an integrated system that includes:
- a shared environment in which health professionals can register, integrate, update and retrieve patients' clinical information;
- a shared environment in which health professionals can store, integrate, update and retrieve bibliographic information, guidelines and documents relating to specific diagnostic and therapeutic issues;
- an environment for communication both between different health professionals working in the same hospital ward, and between health professionals that work in different wards. It facilitates sharing of knowledge and experience and the construction of new knowledge, skills and competences.
The electronic medical record, structured in this way, can be an effective training tool: it promotes a type of training on the job. This training model is particularly effective in modifying the practice of health professionals and in improving clinical outcomes and health care.