RACSEL: Technical Recommendations for Electronic Health Record Implementation

Health system users have evolved just as the epidemiological profile and the available clinical resources have done. This forces us to think of a different institutions to welcome these changes.

Patients are more empowered, have more access to information and are more demanding. New technologies that have been incorporated allow, even under budget constraint conditions, to broaden the horizon of professionals and patients. Technology facilitates the customization and improves the efficiency of healthcare services. But all this must be managed to leverage opportunities using the strengths of each system. The proper implementation of new technologies, then, requires a well thought out institutional and regulatory structure. This must incorporate specific approaches that are considered relevant, such as institutional, infrastructure and interoperability. But, above all, it must be planned to obtain and maintain political and social support.

This document presents a conceptual model on Electronic Health Records (EHR) that contemplates its scope, risks, the organization that is required for an electronic health project, and legal recommendations, standards, use of terminology, and architecture. Also, it includes the critical issues of the regulatory framework to consider for the EHR, such as patient rights, personal data protection, information exchange, and electronic signature, among others. In addition, the cases of the five RACSEL countries are summarized: Costa Rica, Colombia, Chile, Peru, and Uruguay, and is complemented with information from Mexico and Spain.