Medical facilities begin applying electronic medical records from March 1
From March 1, 2019, medical facilities will begin applying Electronic Medical Records, including inpatient medical records, outpatient medical records and other types of medical records as prescribed by the Ministry of Health.
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| Doctors examine and treat people in the highlands of Bao Lac district, Cao Bang. Photo: TG/Vietnam+ |
Circular 46/2018/TT-BYT regulates electronic medical records, developed by the Ministry of Health to better serve people's health care.
The Circular takes effect from March 1, 2019 and will be deployed to all medical examination and treatment facilities under the Ministry of Health.
According to the Circular, the establishment, use and management of electronic medical records at medical examination and treatment facilities that have been granted operating licenses are in accordance with the provisions of the Law on Medical Examination and Treatment.
The implementation principle is that each patient has only one management code, storing electronic medical records at one medical examination and treatment facility.
Electronic medical records must meet the following requirements: must record all information content as in paper medical records; must have the digital signature of the person responsible for the information content entered into the electronic medical record.
Electronic medical records must comply with the protection of personal information as prescribed in Section 2, Chapter II of the Law on Network Information Security. Medical examination and treatment facilities are allowed to use and store electronic medical records instead of paper medical records when meeting the provisions of this Circular.
Electronic medical records include inpatient medical records, outpatient medical records and other types of medical records as prescribed by the Ministry of Health.
The maximum time to update electronic medical records is 12 hours from the date of medical examination and treatment order. In case the medical examination and treatment time lasts more than 12 hours or there is an IT problem, the maximum time to update electronic medical records is no more than 24 hours.
The Circular of the Ministry of Health clearly states that the Head of the medical examination and treatment facility shall proactively develop a plan and deploy electronic medical records at the facility according to regulations.
Based on the consultation results of the prescribed Professional Council or of an independent consulting unit, the Head of the medical examination and treatment facility decides on the management and storage of electronic medical records instead of paper medical records; storage and transmission of medical images instead of printing films and storage of test information instead of printing paper.
According to Circular 46/2018/TT-BYT, the roadmap for implementing electronic medical records is divided into 2 phases.
From 2019 to 2023: Grade I medical examination and treatment facilities and above proactively upgrade their information technology systems to deploy electronic medical records; other medical examination and treatment facilities, based on their actual needs and capacity, prepare the necessary conditions and deploy electronic medical records when meeting the requirements according to regulations.
From 2024 to 2028, all medical examination and treatment facilities nationwide must deploy electronic medical records. In case medical examination and treatment facilities have not yet deployed, they must report to the affiliated management agency; the report must clearly state the reasons and roadmap for deploying electronic medical records, but must be completed before December 31, 2030./.
