Reference information in integral anamnesis development

The article is devoted to semantic content of integral anamnesis - basic part of national integrated electronic health record. Integral anamnesis is a formalized set of the most important clinical data of a patient aimed at safety and continuous medical care both emergency and elective care. A short review of international projects of implementation and trans border exchange of key information about a patient is presented. Information content of integral anamnesis is presented which is developed in our country and includes 15 main sections: disability, benefits, social factors, addiction and occupational hazards, significant vital parameters, blood types and rhesus factor, pathological reactions, vaccination and immunization, epidemiological anamnesis, significant (dispensary) diseases, surgical interventions, medical devices and implants, pregnancies and deliveries, current medications and non-drug treatment. Administration, structure, problems, readiness of reference materials for coding of information presented in integral anamnesis are described. At the moment most of the necessary reference materials are finished and available on the portal of normative-reference information of the Ministry of Health of the Russian Federation (http://nsi.rosminzdrav.ru/): 20 basic and 7 additional ones. At the current stage it provides interoperability of medical information systems in integral anamnesis. Such time-consuming reference books as surgical interventions, instrumental diagnostic studies, federal reference book of medications are being actively developed. The section «Epidemiological anamnesis of a patient» stays practically unformalized. The first step in this direction is development of a reference book of immunobiological medications for specific prophylaxis, diagnosis and treatment. The aim of the study of semantic interoperability for integral anamnesis was reached by development of 27 reference books posted on the federal portal of normative-reference information of the Ministry of Health of Russia; the next stage should be development of technologies of formation and upgrade of the information of integral anamnesis

ИСПОЛЬЗОВАНИЕ ТЕХНОЛОГИИ АВТОМАТИЗИРОВАННОЙ ОЦЕНКИ КАЧЕСТВА ЖИЗНИ БОЛЬНЫХ В КЛИНИЧЕСКОЙ ПРАКТИКЕ ОНКОУРОЛОГИЧЕСКОГО ОТДЕЛЕНИЯ

Objective. The developing and introduction the quality of life (QL) automatized assessment in oncourological patients in clinical practice.Subjects and methods. General questionnaire EORTC QLQ-C30 and modules (QLQ-PR25 and QLQ-BLM30) were selected for QL assessment. The software tools of hospital information system were used for development. There were surveyed 236 oncourological patients.Results. Forms of unitary and dynamic researches were developed for result visualization, interactive modules were developed for data complex analysis. The first results of QL assessment were received. The highest values were in role and social functions (medians were equal 100 points). Fatigue, pain and sleeplessness were disturbed patients most of all (medians — 33,3, 16,7 and 33,3 points respectively). The median of Global health status was not high, only 50 points. There were analyzed three nosological groups of patients: urinary bladder cancer, renal cancer, prostate cancer. And the lowest values of functioning scales were in patients with urinary bladder cancer; also these patients complained of dyspnea reliably more often.Conclusions. The developed technology of quality of life study can be used as a good methodological base for assessment of cure efficiency not only in early postoperational period, but during treatment, and in late time after termination of course of treatment.Цели исследования — разработка и внедрение автоматизированной оценки качества жизни (КЖ) больных онкоурологического профиля в клиническую практику.Материалы и методы. Для оценки КЖ был выбран общий опросник EORTC QLQ-C30 и дополнительные модули (QLQ-PR25 и QLQBLM30). Разработка проводилась с помощью программных средств госпитальной информационной системы. Было обследовано 236 пациентов онкоурологического профиля.Результаты. Для визуализации результатов были созданы бланки однократного и динамического исследований, а для комплексного анализа данных — интерактивные модули. Получены первые данные по оценке КЖ. Наиболее высокие значения отмечались по шкалам ролевой и социальной функций (медианы по 100 баллов). Больше всего пациентов беспокоили усталость, боль и бессонница (медианы — 33,3; 16,7 и 33,3 балла соответственно). Медиана шкалы общего статуса здоровья невысока — 50 баллов. При сравнении 3 нозологических групп пациентов (рак мочевого пузыря — РМП, рак почки и рак предстательной железы) выявлено, что самые низкие показатели по функциональным шкалам были у больных РМП, и достоверно чаще эти пациенты жаловались на диспноэ.Выводы. Разработанная технология исcледования КЖ может стать хорошей методологической основой для оценки эффективности лечения не только в раннем послеоперационном периоде, но и в ходе лечения, а также в поздние сроки после окончания лечения

THE USE OF QUALITY OF LIFE AUTOMATIZED ASSESSMENT TECHNOLOGY IN PATIENTS IN CLINICAL PRACTICE OF THE ONCOUROLOGICAL DEPARTMENT

<p><strong>Objective. </strong>The developing and introduction the quality of life (QL) automatized assessment in oncourological patients in clinical practice.</p><p><strong>Subjects and methods. </strong>General questionnaire EORTC QLQ-C30 and modules (QLQ-PR25 and QLQ-BLM30) were selected for QL assessment. The software tools of hospital information system were used for development. There were surveyed 236 oncourological patients.</p><p><strong>Results. </strong>Forms of unitary and dynamic researches were developed for result visualization, interactive modules were developed for data complex analysis. The first results of QL assessment were received. The highest values were in role and social functions (medians were equal 100 points). Fatigue, pain and sleeplessness were disturbed patients most of all (medians — 33,3, 16,7 and 33,3 points respectively). The median of Global health status was not high, only 50 points. There were analyzed three nosological groups of patients: urinary bladder cancer, renal cancer, prostate cancer. And the lowest values of functioning scales were in patients with urinary bladder cancer; also these patients complained of dyspnea reliably more often.</p><p><strong>Conclusions. </strong>The developed technology of quality of life study can be used as a good methodological base for assessment of cure efficiency not only in early postoperational period, but during treatment, and in late time after termination of course of treatment.<strong></strong></p