The Heart Institute (InCor) in São Paulo has dived into the world of information technology. The traditional medical records, a pile of reports, documents and exam images, is now something of the past. Since August of 2000, patients interned in the hospital have had available to them an unprecedented digitally records, an efficient data integrated circuit that contains all of a patient’s medical history. Within a year all of the 230,000 people who have had a consultation at the institute will also be registered in the digital records. As a consequence of the success of the system – today around 20,000 institute patients already have their digital medical record -, a simplified version of the digital records is being developed which will shortly be at the disposal, at no cost, to any Brazilian hospital that shows interest.
The medical record is a piece of software that allows for the capture and storage of text data, such as the patient’s personal details, documents and laboratory exam results, as well as X-rays and images of more complex exams such as cineangiocardiography (also known as catheterism, or the verification of the blood flow through the heart), computerized tomography, magnetic resonance examinations, echocardiograms and ultra-sonograms. And there is more: even the vital life signs of a person interned in the institution, such as breathing rate, blood pressure, electrocardiogram and oxygen intake, can be seen through the electronic system in real time, allowing the monitoring of the patient at a distance.
The system, unique in Brazil, and with very few similar to it in the world, is the result of a thematic project financed through FAPESP. Begun in 1998, the project is expected to be completed in August of this year. It also involves the Radiology Institute (Inrad), which along with InCor and a further four institutions, make up part of the Hospital das Clínicas (HC) of the Medical School of the University of São Paulo (USP).
The pioneering idea of the InCor system can be perceived in the article “Welcome to the (almost) digital hospital ” published in the March edition of the magazine Spectrum, of the Institute of Electrical and Electronics Engineers, which groups some 377,000 engineers from one hundred and fifty countries. In the article, the author Giselle Weiss says that the Georges Pompidou European Hospital in Paris, conceived to be a model of medicine for the 21st century, has still not got its electronic medical records completed – they have as yet not managed to integrate images and signals into the system. The story also talks about the efforts of giant North American companies such as Oracle (the largest data bank company in the world) and the HealthSouth Corp (the largest health service provider in the United States), to build a complete digital system for a hospital, which should only be ready next year.
According to the electronic engineer Sérgio Shiguemi Furuie, director of the Research and Development unit of InCor’s Information Technology Service and the coordinator of the thematic project, the new medical records system brings with it huge advantages to medicine and to the patients. “With it, the clinic quickly accesses on the screen of its computer all of the medical information (written data, laboratory data and images) about the patient”, he explains. Before, it was necessary to ask for the traditional medical record at least one day before. “If among the examinations there was that of hemodynamics, the doctor must direct himself to a specific sector in order to consult the images”, he explain. Another advantage of the new system is the possibility of various specialists looking at the patient’s records at the same time and in different places, adding dynamism to the diagnosis.
The ten thousand patients interned every year at InCor will also end up winning, because the digital medical record which will eliminate the risk of information getting loss or going astray. Furthermore, by having all of the information integrated into the one place, the patient will be attended to with greater agility and punctuality. The InCor has five hundred and three beds available and there are more than 1.5 million procedures (laboratory examinations, anamneses, radiographies etc.) as well as 3,700 surgeries carried out each year. The institution is the main reference center for the treatment of cardiovascular illnesses in the country.
The creation and implementation of the system has received the approval of the clinical body of InCor. “The digital medical record considerably makes easier the doctors’ lives” argues Eulólio Martinez, the director of the Hospital’s Hemodynamic Service. “The quality of the images, as well as the speed information retrieving and the storage capacity of the system are excellent.” This opinion is seconded by Alfredo José Mansur, the director of the hospital’s general day to day clinic. “Document registration on paper was becoming more and more complicated”, he says. “The new system adopted by InCor is the fruit of a natural evolution. It attends to the needs of the patient and operationally facilitates the practice of medicine”, Mancur further explains.
The service will be even more efficient in a few months time when the doctors will be able to make consultations through the digital medical records of their patients even outside of the hospital – in their offices or at home – and they will be able to receive the less complex laboratory exam results that don’t involve images, through cellular telephones such as WAP (Wireless Application Protocol ) technology. “We’ve already developed these connections and now we’re testing the security protocols”, adds Furuie, who has as his sub-coordinator professor Giovanni Guido Cerri, the director of Inrad.
Besides all this, one can also find at the testing stage the use of mobile devices of the type PDA (Personal Device Assistance) and wireless networks for total access to the digital medical records, including signals and images. “Currently, we’re using two technologies, one based on the protocol Ethernet, with a limited cover in the surroundings of the hospital, and the other using the new generation of cellular telephones (CDMA 2.5G), with cover all of the São Paulo metropolitan area, explains the electronics engineer Marco Antônio Gutierrez, the director of InCor’s Information Technology Service Support Unit and one of the thematic project researchers.
One of the main innovations of InCor’s new digital medical record system when compared with the models existing in other hospitals is the capacity for the storage of 3-dimensional and dynamic images, such as those generated by the hemodynamic examination. This examination is a procedure for the evaluation of the degree of obstruction of coronary arteries and essential for patients who are going to be submitted to the implantation of by-passes. “We carry out around ten thousand hemodynamic exams per year. And now all of them can be integrated into the patient’s medical record”, informs Furuie.
As each of them occupies a space of 300 megabytes, it was necessary to create in the system the capacity of automatically storing more than 3,000 gigabytes (or 3 terabytes) only for the images. They remain on-line for six months and afterwards they are stored for two years on high speed tape. “The viewing of these exams continues to be automatic, but the access takes a little longer, close to three minutes”, explains Gutierrez.
Setting the network demanded the creation of a sophisticated computing infrastructure, which was built starting in 1995, with the assistance of other institutions such as the Financier of Studies and Projects (Finep) and the Zerbini Foundation, involving all of the information technology team as well as various post graduate students. The operational system of the main network servers is Linux and all of the consulting is based on Internet (web) technology. The medical images data bank servers that store the examination make use of 700 gigabytes on-line in disc and a further 3.5 terabytes in the juke-box, a type of integrated file of the network. “With this infrastructure we have the capacity to transmit in an efficient manner exams such as that of hemodynamics with up to thirty frames per second”, points Gutierrez out.
The storing of the images in the digital medical records was only possible after the adoption of an international standard for the transmission and storage of medical images called Dicom (Digital Imaging and Communications in Medicine). The choice of this standard permits the direct connection of the examinations from sophisticated equipment such as tomographs to the network for automatic transmission. Older apparatus that was not adopted to this technology received an interface for converting the images into the standard form.
The digital medical record system has been made secure, inviolable and reliable. Access to the system is only allowed through a password provided to authorized professionals. “We developed a complex system based on users profile”, explains Gutierrez. For example, a clerical assistant has an “A” rating and will have restricted access to determined data within the digital medical record. Health professionals can access other information, while doctors have complete access to the digital medical records. “All of the transactions involving the digital medical record remain registered in the system’s memory, in such a manner as it would be possible to know who had accessed the digital medical record, when and for how long”, explains Furuie.
As to confidentiality, various sections of the system were placed in redundancy (repeated) with equipment functioning in parallel to avoid the discontinuity of the system in case some malfunction occurs. To guarantee the inviolability of the information, the digital medical record system does not allow that data already inserted into the system to be erased or modified. “If there is any type of error, the alteration must be made by way of a rectification”, explains Sérgio Furuie.
Besides the creation and implementation of the digital medical record system, FAPESP’s thematic project also provides for the development of a system that makes possible the integration of all information on the same patient filed in different units of the HC. It is worth remembering that the hospital is made up of six large institutions and three auxiliary hospitals. The idea is to create a wide network where the medical information about patients traffic freely. “Through a common interface, we want to make an integration between the different data bases, respecting the specification of each individual system”, says Furuie. The first prototype of this model of data integration is being set up to allow for the interchange of information between the medical records of InCor and that of the Radiology Institute.
Distributed Environment for the Transmission, Processing and Viewing of Medical Images (nº 97/14206-5); Modality Thematic project; Coordinator Sérgio Shiguemi Furuie – InCor; Investment R$ 754,614.00 and US$ 65,000.00