Interview of TAdviser with the associate director of VTsERM on medical information technologies Mikhail Bakhtin

Mikhail Bakhtin: From the first day of work of the center with treatment of patients we had to conduct selection and accumulation of the valuable data for improvement of medical process. Specialists kept tables with different data on different sectors of work, analyzed them. There was a task: create a prototype of the electronic medical record which those years was called just "database".

On the other hand, in addition to satisfaction of requirements of the center for collecting and the organization of medical data, we needed to provide implementation of everyday technology and administrative processes and to do all this in Russian.

The history of informatization of medical process of VTsERM clinics originates in 2001 when we started the first 10 jobs. Approximately then at us practice of off-budget acceptance of patients started that became an incentive for optimization of important points in work, neglect which meant the missed profit or increase in costs. The set of stages at which purely technical errors leading to loss of analysis results or to duplication of record of patients on acceptance to the same specialist are possible was opened.

For us start of a hospital system with the organization of work on registration of patients, services and maintaining the electronic schedule was the most important. It allowed to arrange interaction with patients.

At the same time we started laboratory system (PIM), and doctors began to receive results of laboratory researches most quickly after their verification in laboratory. It promoted growth of trust of physicians to information technologies in health care, in particular to a hospital system and electronic medical records.

Implementation in 2003-2004 the systems of total barcoding allowed to liquidate even the minimum premises to errors of a preanalitichesky stage of laboratory researches. Start in 2005 DICOM server and connection of all devices of radiodiagnosis in uniform PACS optimized diagnostic process and reduced costs of the center for a film.

In 2008 the uniform supply chain of medicines and medical products in which the way from the supplier through the central warehouse in department and to the patient is traced was built.

All course of life of medicines happens in clinic in a single system. In 2011 we integrated a LAN of two clinics and clinic in a single network and began to work from uniform data center. Now it is absolutely unimportant in what clinic the patient was treated so far where he underwent diagnostic inspections. Doctors got identical access to electronic records of the patient from any point of our center.

2014 is marked by start of the system of turnover of electronic ECGs, uniform for clinic. All ECGs thanks to this system, and not only the description and the conclusion, but also the curve uniform which is taken off in any of clinics are available directly from the electronic medical record on any medical place, and we ceased to be afraid to lose the ECG of the patient.

As for "iron", today our system is distributed on two platforms of own DPC (the main and reserve) on model of a private cloud, it is completely closed on itself, there is no Internet connection. Data on the state of health are special category of personal data therefore attention to their protection is paid corresponding.

All admissions to data are organized through personal cards of the medic using certification of the electronic digital signature (smart card) for complete transparency of all transactions in a system. Arrival and leaving for work, all transactions in any parts of a system have authorship, are traced in dynamics, have gradation of roles for the same employee (the doctor of a hospital, the doctor of clinic, etc.) and different levels of completeness of the provided information.

At bypasses of patients tablets are used - it is some kind of thin client with the same authorized access on a smart card. All data remain on the server, and the tablet executes a role of a player, the browser, no more – it is impossible neither to lose data, nor to steal.

Mikhail Bakhtin: We started search and the choice of a system in far 1998. Then we jointly made the decision to stop development of the electronic medical record by own forces. Agree, any clinic does not do itself the biochemical analyzer or the computer tomograph. And with a medical system — we decided to select the ready, professionally developed system which can be adapted for our technology processes.

We were lucky to come to the company of the joint venture. The automated workplace which was and is a partner of InterSystems so far together they suggested to implement the medical and laboratory systems of the Australian company TrakHealth - MedTrak and LabTrak, respectively.

The data storage model in object-oriented became the key moment of the choice DBMS Caché. The relational model of data storage perfectly is suitable for the tasks connected with an accounting and inventory control. The information about the person, about his diseases and process of treatment best of all keeps within an information model of "a tree of objects". As confirmation of correctness of our choice it is worth noticing that electronic medical records of the lead world medical institutions are implemented based on Caché DBMS.

Mikhail Bakhtin: Three factors defined our choice for benefit of the joint venture. Automated workplace. First, the company had experience of informatization of different fields of activity of medical institutions. Secondly, had unique experience with foreign medical information systems which applied when developing own domestic MIS qMS, in particular, used Caché DBMS. At last, the company was located in our city, and it was important when to us it was necessary to interact often and long during implementation of information processes in work of clinic.

In 2010 all electronic cards of patients were transferred to MIS qMS. Today all VTsERM clinics work in a common information space, the central place which the Russian MIS takes. Reliability of work provides uniform DPC.

Mikhail Bakhtin: The first that we managed to make with a support on the IT system, it to provide high quality of delivery of health care with a global growth of intensity of work. The second — to provide observance of all rules of financial discipline in the conditions of interaction with several financing sources of medical process and also to achieve the maximum satisfaction in medical supply of departments in the presence of minimum sufficient stocks in warehouses.

First of all we organized jobs in registry for fall forward of an initial stage of service of patients. It allowed to adjust accounting of patients and the executed services. At registration of the patient the registration number – a unique identifier of the patient began to be assigned to it. Thus we could liquidate loss of analysis results, inspections because of the mistakes made in writing of surnames of patients as the registration number allows to compare results with passport data of the person unambiguously.

After one more workplace was set in a staffroom, doctors quickly estimated that the information system is fine data source as there was an opportunity to keep track of results of treatment long before the paper clinical record is created. At least, choice reaction time about modification of medical process with a possibility of reduction of number of koyko-days when preserving quality of medical care was reduced by day. These results were received quickly enough and extremely inspired us for implementation of a hospital system in other fields of work of VTsERM.

Moreover, I can tell that work in a system then anticipated interaction of people on social networks: coordination of actions of nurses, laboratories and attending physicians is no other than remote coordination of professional communication in virtual space.

Doctors saw effect, process of avalanche growth began: it is more than data – more advantage, it is more than advantage – more involvement of doctors, it is more than involvement of doctors – even more data, etc. Of course, there were enthusiasts, were indifferent and there were opponents of implementation of IT in usual workflow. But the successful example of pioneers convinced also other divisions of the urgent need of new technologies so shortly and other came to the management and demanded to supply them with the same IT solutions, as at more "advanced" colleagues. The high level of informatization allowed to involve more young people and the trained or just motivated employees that laid the good foundation on long-term development of the center in IT perspective in general.

Mikhail Bakhtin: The main task on the near future – completely to pass to electronic medical records which will have the status of the legally significant electronic document. It will save us from duplication of information on paper, from archives of paper stories of diseases, will save means which went for acquisition of the paper, printers and cartridges and to direct them to quality improvement of medical process and comfort of patients.

As for work with medical data, a system develops in the direction of accumulation of volumes of the advantage received from their processing. For example, all data from laboratories arrive on the server where there are settings on certain levels of different indicators: if on any patient they reach critical values or exceed them, a system notifies on it doctors at once and there is correction of medical process. It allows to improve significantly preventive influence, it is in fact already decision-making support system.

Today we saved up 190 GB of text and numeric data in 15 years of work and about 30 Tb of pictures in 10 years of work of two clinics – mammography, multilayer modern pictures of tomographs and x-ray devices. The sizes of packets of graphic files can reach 50 MB. There are calls connected with transmission rate and an output of such files for use by doctors in the work. Speed of processes today such is that even 5 minutes of waiting in stream process of data exchange are unacceptable.

We work on integration of clinical records from other clinics – they are scanned and attached to the e-card in the form of graphic files.

Mikhail Bakhtin: Looking back for 15 years in the past, it is necessary to tell that informatization, computers already firmly entered life of all medical institutions. Yes, in different degree. Somewhere computerized so far only registry and the statistical recording. There are clinics which reached total informatization of medical process. It is necessary to recognize that countrywide we still lag behind the overall level of informatization of medicine both in Europe, and in America. But the speed with which we overcome this gap instills confidence that we will successfully overcome it in the next 5 years.

Considerably rates of implementation of the EDS in the electronic clinical record increased though process is extremely difficult. Take clinical blood test – there 26 indicators of different parameters of the studied material should be certified by the signature of one doctor, and it is very simple to visualize it in electronic form and to create the paper copy or the version. And here when we do biochemical blood test when each separate parameter is investigated by the certain specialist — and such can be at least eight — each of them should certify data the signature. Each signature has the details for YuZEDO which occupy half-pages. It is clear, that the paper copy of biochemistry of blood – 8 digits — give 8 pages of details to the EDS.

There should pass some time before the critical mass of people collects, for 100% ready to live only in an electronic paradigm and to take all advantages of electronic document management (e-document flow). Until in the industry well-defined rules of failure from records on paper and transition to electronic document management are developed, criteria and rules of interaction with other departments at e-document flow are formulated. Now we endure a classical transient period. Conducting records in electronic history, their printout and signing by the doctor is the compromise allowing to move steadily towards e-document flow, but at the same time creating traditional paper clinical records which are necessary for interdepartmental document flow.

The electronic clinical record is pull-technologies: history "is tightened" there where the patient came, it follows him. It is clear, that in view of the highest responsibility in innovation medicine in operation algorithms of medical institutions are justified and are accepted only when their efficiency and reliability are completely confirmed. Increase it by scales of Russia, and it will become clear why the speed of IT implementations here a bit different, than in Europe. The leading countries of informatization on the scales at best are equal to an average on value in health care to the region of Russia, so, and it is impossible to speak about complete absolute transfer of foreign experience on a reality of the Russian Federation.

Mikhail Bakhtin: I cannot categorically claim that our strategy of management of IT infrastructure is the most competent. I can only note that now we have three partners who in the mode of outsourcing perform problem solving according to software, iron and network technologies. And here actually the IT service of clinic is integrator of efforts of all participants of process. Probably, the secret of successful development of the project consists in it.

Mikhail Bakhtin: Every day in a medical information system more and more state-of-health data of health of patients and how there is a medical process are collected. Our global task — to learn to look for and find in this information array new patterns "on the fly", to create new knowledge and to a descent to apply them in medical process.

In our medicine there are specialists with historically developed patterns of scenarios of inspection and record. And is (and their majority) with quite any form of record – even attempts to call for standardization of several different specialists not always found understanding in one office. Traditionally in the Russian Federation the clinical record – the unrolled compositions; went west on the way of reduction of volumes of record through exarticulations only of the main contents.

It is necessary to work in the direction of standardization of these moments in industry scales to minimize the addresses to programmers concerning each block of the IT system with a request "were drunk up" under these or those tasks. We implement work on scaling of the IT system within our filial structure, but in addition we prepare also for the solution of new tasks of integration with other medical institutions of a national health care system.