The Impact of Using the Electronic Disease Process Form in Improving the Performance of Diagnosis, Prescribing the Type and Dose of Medicine by the Health Care Providers and the Patient’s Response to Treatment in the Electronic Hospital of Mashhad Velayat in ۲۰۲۲

Background and aims: In health care organizations such as hospitals, medical record forms suchas the disease course form are the most important tools for storing and retrieving information andanalyzing health care. Their incomplete registration, besides threatening the patient’s health, createsmany problems for the patient in pursuing treatment and legal issues, such as referring casesto legal medicine, supplementary insurance, occupational accidents, and disability, on the otherhand, it also causes problems for hospitals such as increasing hospital deductions and medicalerrors. As a result, hospitals turned to innovative models based on advanced medical technologiessuch as electronic health, intelligentization of processes, and smart hospitals. Data and a hugeamount of information in these forms can be very useful for physicians’ better decision-making.This study aimed to investigate the impact of using the electronic disease course form on improvingthe performance of diagnosis, prescribing the type and dose of medicine by the health careproviders, and the patient’s response to treatment in Mashhad Velayat hospital in ۲۰۲۲.Method: The disease process form is the documentation of the patient’s response to the treatment,including the notes of the patient’s admission in the form of subjective information, all thetreatments provided and the patient’s response to the treatment, the final notes of the patient’scondition at the time of discharge, recommendations at the time of discharge such as the patient’sphysical activity and diet, notes related to the progress of the disease at the time of death, whichshould all be recorded. On the other hand, recording general and vague things to show the patient’scondition, such as “the general condition of the patient is good”, should be avoided. Inthe electronic Velayat hospital of Mashhad, the disease process form was prepared and designedaccording to the promulgated instructions by the Ministry of Health, Treatment, and Medical Education.To implement it, an expert system has been used, which is one of the branches of artificialintelligence and is being greatly expanded. One of the ways that knowledge can be presented inan expert system is through a rule-based system that follows an if/then structure. The informationthat appears in the ‘If’ section is logically related to the information that appears in the ‘Then’section. By choosing each item (if) different decisions (then) are obtained. Finally, by displayingthe response of the patient to the treatment in the section of the patient’s condition, which includessurgery and medication, the clinicians are helped in determining the type and dosage of the medication.Results: In other hospitals, the process of recording disease process form is paper-based withoutany intelligence or warning alarm. In this study, in the process of electronic recording by displayingthe tests of the patient that are outside the normal range (“If” in the rule of an expert system),how the response of the patient to the treatment is determined (“Then” in the rule of an expertsystem), which leads to the improvement of the performance of diagnosis and prescription, systematicrecording of the disease by the physician. It is possible to check the effect of the medicineand the recovery process of the patient by displaying the status of the vital signs of the patient andchanges in paraclinical tests, such as blood tests during patient visits. Conclusion: In this study, based on the electronic prescribing approach, by displaying the patient’sparaclinical tests and vital signs in the form of the disease process, the performance of diagnosisand prescribing of the type and dosage of the medication by the physicians was improved.

کلیدواژه ها:

Artificial Intelligence ، Expert Systems ، Disease Process Form ، Electronic Health ، Smart Hospital