Thanh Hoa makes a breakthrough in deploying electronic medical records to improve the quality of medical examination and treatment.

Thanh Hoa is pioneering the application of electronic medical records. This solution not only improves the quality of medical care but also creates conditions for hospitals to operate more effectively.

Implementing electronic medical records aims to improve the quality of medical examination and treatment.

Digital transformation in healthcare , with a focus on the implementation of electronic medical records (E-records), is an inevitable trend aimed at improving the quality of medical examination and treatment, increasing management efficiency, and making rational use of resources. E-records allow for the standardization of information, reduce reliance on paper medical records, and create an electronic health data repository to serve the continuous and comprehensive care, monitoring, and management of children's health.

Thanh Hoa Pediatric Hospital is the province's leading specialized pediatric hospital, with a planned capacity of approximately 900 beds, 22 clinical departments, 7 paraclinical departments, and numerous functional rooms. It handles over 200,000 outpatient visits and over 60,000 inpatient treatments annually. In this context, implementing the Electronic Medical Record System (EBSS) not only meets the digital transformation roadmap directed by the Ministry of Health but is also a crucial solution for improving service quality at the hospital.

Each patient is managed using a unified identification number throughout the hospital. All examinations, treatments, and paraclinical tests are linked to a single record, creating a complete patient record lifecycle at Thanh Hoa Pediatric Hospital.

The hospital implemented a hospital management software system (HIS) early on and was selected as one of the pilot units for the Ministry of Health's e-health program. Recently, the hospital has focused on upgrading its IT infrastructure, including servers, storage devices, intranet, Wi-Fi, firewalls, security devices, and workstations in various departments, to meet the requirements for operating the e-health program throughout the entire hospital.

Thanks to thorough preparation, the IT infrastructure criteria group has reached a high level (level 7), ensuring stable operation and meeting the storage and processing capacity requirements for electronic medical records. In addition, the HIS system manages the entire process of medical examination, inpatient treatment, medication dispensing, hospital bill payment, health insurance management, queuing, appointment scheduling, and supports cashless payments.

The LIS (laboratory) and RIS/PACS (radiological imaging) systems are deployed synchronously, connecting bidirectionally with the HIS and integrating data into the electronic patient record system, allowing doctors to access test results and images directly on patient records.

The software systems for managing operations (finance and accounting, assets and equipment, administrative documents, human resources, quality management, training, scientific research, etc.) are highly computerized, effectively supporting hospital management.

The criteria for information security, data backup, and recovery are ensured through role-based access control, regular data backups, and recovery plans in case of incidents. Based on this, the hospital's information system platform has the technical capacity to implement e-health care on a hospital-wide scale.

According to Thanh Hoa Pediatric Hospital, the Electronic Medical Record System (EBSS) has been implemented in 100% of the hospital's clinical and paraclinical departments, applicable to both inpatients and outpatients.

According to Dr. Nguyen Huu Thanh, Head of the General Planning Department at Thanh Hoa Pediatric Hospital, the Electronic Medical Record System (EBSS) has been implemented in 100% of the hospital's clinical and paraclinical departments, applicable to both inpatients and outpatients. The EBSS system is integrated into the hospital's software platform (EMR/EHC), closely interconnected with HIS, LIS, and PACS, ensuring that data is entered once and used multiple times.

Each patient is managed using a unified identification number throughout the hospital. All examinations, treatments, and diagnostic tests are linked to a single record, creating a complete patient history lifecycle.

The e-medical record system eliminates the readability issues caused by handwriting, reduces the risk of errors from copying information, centralizes clinical and paraclinical information on a single platform, and supports doctors in making faster and more accurate decisions. The system allows for alerts regarding drug interactions, allergies, and duplicate prescriptions, contributing to improved treatment safety.

"Thanh Hoa Pediatric Hospital has implemented the Electronic Medical Record System (EBSS) throughout the entire hospital, achieving a high level of IT application as required. The EBSS has initially affirmed its important role in standardizing and digitizing the medical examination and treatment process, improving professional quality, increasing management efficiency, and enhancing patient experience. In the future, the hospital needs to continue to refine and optimize data entry processes, simplify operations on the software to reduce the workload for medical staff. Training, support, and supervision of compliance with the use of EBSS in departments and wards should be strengthened. Along with that, communication and guidance for patients and their families on using digital utilities should be promoted to maximize the benefits of the system. Gradually, the EBSS data should be connected and integrated with higher-level medical information systems and other health platforms, contributing to building a digital health data ecosystem to serve children's healthcare throughout the province," Dr. Thanh emphasized.

At Nghi Son General Hospital, the implementation of the Electronic Medical Record System is an important step in the digital transformation roadmap of the healthcare sector.

At Nghi Son General Hospital, the implementation of the Electronic Medical Record System (EBSS) is a crucial step in the digital transformation of the healthcare sector. After a period of implementation, the hospital has achieved many outstanding results, contributing to the innovation of management methods, improving professional efficiency, and bringing practical benefits to patients.

The hospital has implemented electronic medical records since May 2025. The official assessment of electronic medical records began on September 19, 2025. The goal is to achieve a paperless electronic medical record system by March 31, 2026.

First, the hospital has invested in a comprehensive information technology infrastructure, including server systems, network connections, HIS (High-Intensity Service), image storage and transmission systems, and data entry and digital signature equipment for medical staff. As a result, the entire medical examination and treatment process is digitized, enabling quick and accurate information exchange between departments. The information technology infrastructure has reached level 6. Information security criteria at level 2 have been met. 100% of administrative documents are digitally signed and processed through the iOffice software, reducing paperwork, increasing productivity, and ensuring data security.

The hospital reorganized the reception area, and the social work team guided patients to register using smart kiosks. This ensures transparency in the registration process for medical examinations and treatment.

The e-medical record system significantly reduces the time spent on recording, storing, and searching medical records. Information on examinations, treatments, test results, diagnostic imaging, etc., is automatically updated and synchronized in real time, making it easier for doctors to look up, compare, and make more accurate treatment decisions. Data exchange with the Vietnam Social Insurance also facilitates smooth data sharing, reducing errors and shortening the time for processing medical expense claims.

The use of e-health records saves waiting time, reduces administrative procedures, and ensures transparency in the treatment process. Patients can easily track their personal medical information, test results, and appointments through the electronic portal or mobile application.

Mr. Le Van Cuong, Director of the Thanh Hoa Department of Health, inspects the implementation of the Electronic Medical Record System (EBSS).

Besides the achievements, the hospital also noted some difficulties such as: the limited IT skills of some staff members, and the large volume of data requiring strict standardization and security. However, thanks to the close guidance of the Thanh Hoa Department of Health and the efforts of all staff, the electronic medical record system at Nghi Son General Hospital is becoming increasingly complete, contributing to improving the quality of healthcare and moving towards the goal of a paperless hospital in the future.

According to information from the Thanh Hoa Department of Health, currently 92% of hospitals in the province (100% public and 75% private) have completed the implementation of e-medical records, making Thanh Hoa one of the leading localities nationwide in healthcare digital transformation.

The results achieved demonstrate the strong commitment to digital transformation in Thanh Hoa's health sector, reflecting the collaboration of the government, healthcare facilities, and technology companies. In the coming period, the Department of Health will continue to require hospitals to improve operational processes, ensure data security and the legal validity of electronic medical records, moving towards a "paperless hospital" model.

The plan is to guide hospitals to adopt a lean management model (LEAN), install queue display screens in high-traffic areas, apply technology to predict waiting times, and standardize the process of recording, updating, and encoding nursing care information in patient records to ensure consistency and uniformity throughout the province.

Ngoc Hung

Source: https://suckhoedoisong.vn/thanh-hoa-dot-pha-trien-khai-ho-so-benh-an-dien-tu-nham-nang-cao-chat-luong-kham-chua-benh-169251107153944808.htm