In concretizing Resolution No. 57-NQ/TW (December 22, 2024) of the Politburo , Bai Chay Hospital is promoting innovation in medical examination and treatment through the connection and integration of artificial intelligence (AI) with its electronic medical record system. Based on digitized medical data, this solution contributes to supporting professional expertise, reducing administrative pressure on medical staff, and improving the quality of service for patients.
Leveraging data to improve treatment quality.
Experiencing chest pain, shortness of breath, and persistent fatigue, Mr. Dinh Khac Hoan (from Duong Hoa commune) went to Bai Chay Hospital for examination. After testing, doctors determined he had coronary artery stenosis and needed stent placement. This wasn't the first time Mr. Hoan had received treatment for cardiovascular disease at the hospital; four years prior, he had undergone two coronary artery stent placements. Following the intervention, Mr. Hoan's chest pain and discomfort significantly decreased, and his health stabilized.
According to Dr. Dinh Danh Trinh (Head of the Cardiology Department), for patients who have undergone cardiovascular interventions or have multiple underlying conditions, data on their medical history, medication use, and previous examination and treatment results are crucial. When this information is fully updated in the electronic medical record, doctors can quickly understand the patient's condition, conduct a more comprehensive assessment, and thus choose the appropriate intervention plan and provide specific advice. This also forms the basis for artificial intelligence applications to further support data aggregation, risk warning, and contribute to improved safety during treatment.
Utilizing electronic medical records has proven effective in treating chronic diseases. Ms. Pham Thi Chi (Zone 1, Tuan Chau Ward) has suffered from diabetes for 15 years. Every month, she visits the hospital for check-ups and medication. When she experiences unusual symptoms requiring hospitalization, doctors can quickly access her monitoring history, medication use, and test results through her updated electronic health records. This provides doctors with additional information to assess the disease progression and adjust treatment accordingly.
According to Dr. Do Doan Trong (Head of the General Internal Medicine Department), with endocrine diseases such as diabetes, hypothyroidism, adrenal insufficiency, pituitary insufficiency, etc., the effectiveness of treatment depends greatly on long-term monitoring. Each follow-up visit, test results, or changes in the treatment protocol are important data for doctors to assess the patient's response to treatment. When this data is centrally managed in electronic medical records, the patient monitoring process becomes more systematic.
Since 2020, Bai Chay Hospital has been one of the leading units in the province to meet the criteria for applying electronic medical records. Experience in medical examination and treatment shows that electronic medical records are not just about replacing paper records with digital ones. Their greater value lies in creating a continuous medical data repository that can be connected, retrieved, and used to support professional activities. When data is fully updated, accurate, and used effectively, doctors have a stronger basis for comprehensively assessing patients, especially those with chronic diseases, the elderly, those with multiple underlying conditions, or those who have received treatment at the hospital multiple times.
Adding "digital assistants" for doctors.
Bai Chay Hospital is currently a Grade I, specialized hospital of the province, receiving nearly 1,500 outpatient visits and over 1,000 inpatients daily. With such a large workload, the medical staff not only face pressure in diagnosis and treatment but also have to perform many administrative and professional tasks such as recording patient progress, reviewing medical history, checking prescriptions, compiling paraclinical results, completing discharge papers, digitally signing, and checking patient records.
Driven by the need to maximize the value of electronic medical records, reduce manual operation time, and improve the quality of professional support, the team from Bai Chay Hospital (Deputy Director Tran Thanh Luan; Head of Information Technology and Communications Department Pham Viet Hung; Head of Quality Management Department Hoang Minh Tuan) developed the initiative "Solution for integrating AI with the electronic medical record system to improve the quality and efficiency of medical examination and treatment." This initiative was recently awarded First Prize in the "Search for initiatives and solutions for administrative reform in Quang Ninh province in 2025" competition.
Based on the practical experience of operating electronic medical records in hospitals, the authors proposed a solution to connect the existing electronic medical record software with an artificial intelligence platform to support doctors and nurses in recording, managing, and analyzing records, alerting to drug interactions, suggesting diagnoses, planning care, summarizing medical records, and other professional tasks. Notably, the AI is not used as a separate software but is integrated directly into the electronic medical record process. Based on existing data on symptoms, medical history, drug allergies, test results, imaging, prescriptions, and treatment processes, the system can analyze, synthesize, and provide supportive suggestions. Doctors remain the ones who review, evaluate, and make the final decisions. The AI acts only as a "digital assistant," providing healthcare professionals with an additional reference channel in their professional work and record completion.
In outpatient settings, for patients with multiple underlying conditions such as hypertension, diabetes, kidney failure, or a history of drug allergies, doctors often have to review a lot of information before prescribing medication. When AI is integrated with electronic medical records, the system can automatically aggregate important data such as age, gender, underlying conditions, allergy history, most recent test results, medications used in previous visits, etc. From there, the system provides warnings or suggestions for doctors to consider, helping to shorten search time and reduce the risk of missing information.
For inpatients, AI can assist in summarizing the treatment process during consultations, transfers between departments, or discharge. Instead of having to reread entire records that take days, the system can filter key information such as the reason for admission, disease progression, clinical test results, medications used, procedures or surgeries performed, treatment response, and discharge status. This summary helps doctors quickly grasp the overall case and also assists in preparing discharge papers and summarizing medical records according to prescribed templates.
In the prescription process, AI can assist in warning about drug interactions. When a prescription includes a combination of medications that poses a potential risk to patients with underlying conditions or abnormal test results, the system will alert the doctor to consider adjustments, further monitoring, or choosing a more appropriate option. This function is crucial for the elderly, those with multiple chronic diseases, and those who need to use several medications simultaneously.
Dr. Hoang Minh Tuan (Head of Quality Management Department) shared: In hospital quality management, medical records are a very important component, requiring completeness, accuracy, and timeliness. When AI is integrated with the electronic medical record system, reviewing records becomes easier, from detecting incomplete or unsigned records to identifying missing or inappropriate content. This tool helps departments reduce manual operations while improving the efficiency of checking and monitoring record quality. In addition, functions such as speech-to-text conversion, automatic standardization of recording content, and support for nurses in developing care plans also help medical staff update medical records faster, allowing them more time to communicate, advise, and care for patients.
It is estimated that the implementation of this initiative at Bai Chay Hospital could save more than 1,000 man-hours per year for the medical staff, equivalent to approximately 250 million VND in labor costs. More importantly, the system is highly appreciated by medical staff, with a satisfaction rate exceeding 90%. For patients, the AI application contributes to shortening waiting times, supporting improved quality of diagnosis and treatment, and making health consultations and explanations clearer and easier to understand. In the future, the hospital will continue to refine and share experiences, aiming to expand the "Smart Hospital" initiative to other medical facilities in the province, contributing to building a modern, sustainable, and patient-centered healthcare system in Quang Ninh.
Source: https://baoquangninh.vn/doi-moi-sang-tao-trong-kham-chua-benh-3406929.html
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