On the Issue of Automation of Electronic Documentation in the Anesthesiology and Resuscitation Service

Abstract

Abstract. The current stage of healthcare development is characterized by the widespread introduction of medical information systems with the unification of technological processes and a complete transition to electronic document management; one of the most important components of which is the automatic maintenance of electronic medical records. However, today, real practice is facing a number of challenges and problems, the solution of which is becoming a top priority. The Aim of the Study. was to analyze the current state of digitalization of the anesthesiology and resuscitation (A&R) services in the country’s medical institutions towards the introduction of automated document management. Material and Methods. An expert assessment of the digitalization of A&R services (departments) of 235 multidisciplinary hospitals was conducted, including the evaluation of its level, leading components and their structure in the overall sample. Information from a multicenter questionnaire study approved by the Federation of Anaesthesiologists and Reanimatologists of Russia was used. Results. The study showed that the functionality of the medical information system in each particular hospital differs depending on the developer and the technical capabilities of the hospital itself. The study revealed that electronic document management in the field of A&R, including fully automated ones, is currently fraught with a number of problems (barriers), including technical difficulties, the need for staff training, issues of confidentiality and data security. Conclusions. Automated electronic document management requires a comprehensive solution to issues of hardware and software, connection of special equipment, and personnel training. In addition, the successful integration of electronic A&R records into medical practice requires active cooperation from all stakeholders: medical staff, IT specialists, medical institution administration, and health authorities.

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