Electronic patient chart as the final step in digital transformation

Decades ago, we were used to paper hospital charts at the bedside, recording information about a patient's treatment. However, the path of digitalisation is moving towards the development of an electronic version of this chart. The solution is called the electronic patient chart, and it allows patient-centred, safer therapy, more reliable data, and decisions about the next steps of treatment. But even before that, the digitalisation of basic processes is essential, as only then can the chart become operational in practice.

The essence of electronic patient chart, as emphasised by Anže Droljc, the Director of Business Development at Better, is to provide medical personnel, especially doctors, with all the essential current information at a single click on a computer or a smart tablet. This allows them to quickly assess the patient's current condition. It provides insights into the patient's vital signs, working diagnosis, prescribed medications, tests, procedures, and how the patient's condition is changing. Since the data is automatically generated through informatics, it saves time as there is no need to transcribe them, resulting in fewer errors.

"This is an analytical tool that assists doctors in making decisions about further treatment," explains Droljc. For nurses, it is a tool that enables them to plan their work more effectively. Within the electronic patient chart, there are also more detailed modules where detailed plans are prepared for each patient. It can be fully customised for different departments in hospitals, depending on their speciality. "The key will be solutions that can easily adapt to different specialised departments," he adds.

The importance of the digitalisation of supporting processes

Electronic patient chart is, or will be, the final step in digital transformation. Before that, the digitalisation of basic clinical processes, where all the necessary data is generated, is essential. As explained by Droljc: "From the digitalisation of the medication prescribing and management process to laboratory, microbiological, and radiological examinations, and care... It is the only way that the basic data needed for electronic patient chart can be accessible."

In Slovenia, some hospitals are still entirely paper-based, while others have well-digitised basic processes but lack electronic patient chart. There are also cases of such charts already implemented in some hospitals.

"Healthcare is a field that requires time, so no step should be skipped in the process of digital transformation," warns Droljc. Based on experiences from abroad, the top priority in digitalisation should undoubtedly be the area of medication, he believes. It should be followed by the field of laboratory and other examination orders and then electronic documentation. Essential for creating and managing those charts will also be the digitalisation of care. "In the process of digitalisation and the implementation of the electronic patient chart, it will be necessary to follow the guidelines of the new Slovenian digital healthcare strategy. The first requirement is that, after the final decision to digitise, there will be the time and resources for it," he says.

Challenges of electronic patient chart

There are still several challenges in the digitalisation process. In addition to funding for purchasing software, resources for digitally educating end-users and managing the project within hospitals, as well as providing additional training for decision-makers, are essential. "The key players in hospitals, who need to have the time for digitalisation, understand it, know what they want, and why changes are necessary, are crucial," emphasises Droljc.

Digitalisation following the experience from abroad?

According to Droljc, Slovenia will need to accelerate healthcare digitalisation following the model from abroad by allocating more resources to hospitals that are further along in the digitalisation process and are better prepared. "In this way, we would establish examples of best practices, enhance knowledge, and through these examples, build national teams that can set the wheels of digitalisation in motion in other hospitals and bring them to a minimum level of digitalisation," suggests Droljc.

Best practice example from Catalonia

In Catalonia they have opted for a gradual digitalisation process with the goal of establishing a digital healthcare platform in all of their 68 hospitals and building a structured electronic patient record on the openEHR standard, just like in Slovenia, while using the FHIR standard for operational and demographic data. As the first user case of digitalisation, they selected the process of electronic prescribing and medication management. Research and best practices from around the world indicate that this brings significant benefits, including patient safety, improved treatment outcomes, fewer complications, and reduced hospitalisations.

The article was originally published in 'Medicina danes' in October 2023.