POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS

Chapter 1
THE PROBLEM AND ITS BACKGROUND

INTRODUCTION

Santo. Tomas Integrated High School was first known as Calauan Stand-alone Senior

High School and later Calauan Senior High School. It was established in school year 2016-

2017. The Santo Tomas Integrated High School approximately has 1300 Students and sure

38 Faculty Teachers. The school clinic is one of the important facilities of a school, so the

developer decides to build a system related to the school clinic.

Santo Tomas Integrated High School has only one school nurse. The clinic's nurse will

have all the necessary medical records for students' patients encoded. Also, the records of

the students and faculty are handwritten. The nurse said that the hard copy of students

medical records is at calauan health center. The creation of medical record systems was

needed because it will bring a more efficient and secure processing of medical records in

Santo Tomas Integrated High School.

An information-intensive industry is healthcare. From sources including hospitals,

primary care organizations, clinics, and laboratories, it creates enormous volumes of data.

Most healthcare data is still processed manually, despite decades of experience using IT in

other industries. There are also some unique difficulties when using IT in the healthcare

industry. Problems with privacy and security, the complexity of medical data, and the lack of

a universal national patient identity in many nations are major obstacles. One of the biggest

is a general lack of knowledge about the advantages and dangers of information technology.
 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 2

There isn't a coordinated, standardized system that offers a safe approach to

incorporate all of a person's health data in one location. The management of healthcare will

be more effective if all data are incorporated into a structured information system. This

makes it challenging for healthcare providers to have a centralized and comprehensive view

of the patient information. Additionally, enabling patients access to their own medical records

will motivate them to take an active role in their own care. This would improve the patient-

caregiver interaction as well. In the current state of health records, seeing a new doctor

requires filling out new forms, getting new tests, and having new conversations. A system like

this would also save money. Naturally, the patients will pay more as a result.

Duplication of records can be prevented in an integrated health record system, which lowers

the overall cost of healthcare. Healthcare facilities all over the world are urged to create

Electronic Health Record (EHR) systems for numerous reasons. Personal health record

(PHR) systems are suggested for patient-centered use. PHR would track all Electronic

Health Records from various encounters with various health professionals. PHR is one tool

that can give individuals more control over their own healthcare. It has been observed that

customers who are knowledgeable about their ailments tend to comprehend, adhere to, and

ask more insightful queries.

An entity that provides healthcare may build an electronic medical record (EMR),

which is a digital medical file. EMR typically function as a component of a neighborhood

standalone health information system that enables record archiving, retrieval, and editing. It

serves as the EHR's fundamental building piece and information source. The longitudinal

record made feasible by RHIO's is the Electronic Health Record.

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 3

Clear interdependencies exist. The PHR relies on the user to manually input crucial data, like

laboratory findings, in the absence of links to the EMR. The PHR cannot receive data from

various providers if there is no Electronic Health Record.

A PHR is typically an individual-created and -maintained health record. A perfect PHR

would compile information from several sources to give a thorough and accurate overview of

a person's medical history. Anyone with the required access credentials can examine this

information online thanks to PHR.

The research topic of creating a cloud computing-based web enabled PHR system is

very alluring but challenging. Patients can gather and manage their health information using

such a system. Various authorized people may be able to safely access patient records from

any location with its help. This offers a very nice illustration of the efficient application of

information technology (IT) in the healthcare industry.

OBJECTIVES

The General Objective of this study is to design and develop a Medical Record

System for Santo Tomas Integrated High School for encoding of Students medical records

efficiently.

SPECIFIC OBJECTIVES

1. To create a module to measure the numbers of students who are in

underweight, normal, and overweight.

2. To create a module that will provide a yearly monitoring of medical records

using the system.

3. To create a module for security of students medical records.

4. To test and evaluate the system.

5. To document the systems

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 4

THEORETICAL FRAMEWORK DIAGRAM

Administrative
Patient Data
Data
& Information
& Information

Medical Record
System

Provider Data Clinical Data

& Information & Information

Figure No. 1 Medical System Diagram

This research is anchored on Ayu Wijaya's Medical Record Laboratory

Electronic Information System Design Analysis. This study aims to create a system design

information record medical electronic where is the recording system medical electronic is

system that provides information completeness of patient data and record medical during

maintenance and storage all patient data.

The development of information technologies and modern communications, the

emergence in clinics of a large number of automated medical devices, tracking systems and

individual computers led to a new round of interest and to a significant increase in the

number of medical record systems (MRS) clinics, moreover, as in large medical centers with

large information flows and in medium sized medical centers and even in small clinics or

clinical departments.
 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 5

CONCEPTUAL FRAMEWORK
Data Elements
Purpose The data elements that will be
collected and stored in the medical
The purpose of the medical record system should be identified.
record system should be defined clearly. These may include patient information,
This includes identifying the key height, weight for the BMI results.
stakeholders involved, such as
healthcare providers, patients, and
specifying their specific needs.

Data Collection
Architecture
The methods of data collection
This may include deciding on the should be determined. This includes
type of database to be used, the data identifying the sources of data, such as
storage system, and the interface students, and patients, as well as the
through which the data will be accessed. methods of data collection, such as
manual entry or automated data
capture.

Data Analysis
Data Management
The analytical tools and
The management of data should techniques that will be used to analyze
be addressed, including the processes the data should be identified, including
for data cleaning, data transformation, methods for identifying patterns, trends,
data integration, and data quality and anomalies.
control.

System Evaluation Data Visualization

The effectiveness of the medical The ways in which data will be
record system should be evaluated presented to users should be designed,
regularly to ensure that it meets the such as tables, graphs, charts, and
needs of the stakeholders and to identify dashboards.
areas for improvement.

Figure No. 2

Using this conceptual framework, a medical record system can be designed and

implemented to support healthcare providers, patients, and other stakeholders in delivering

quality care and improving health outcomes.

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 6

STATEMENT OF THE PROBLEM

In almost 6 years of manual processing of medical records of Santo Tomas Integrated

High School. The school encounter various problems regarding in the manual processing of

medical records.

Here some questions that the Medical Records System can answer.

1. How secured the current manual process is in storing and updating medical records?

2. How long does it take for a medical nurse to finish encoding all the medical records

of students and faculty?

3. How long does it take for the nurse to find whose students is malnourished or

normal?

HYPOTHESIS

The implementation of a medical records system in a school will lead to improvements

in students' health outcomes.

School administrators and health professionals will be better equipped to identify

potential health issues and implement interventions that promote healthy habits and

lifestyles. The hypothesis further implies that with the help of the Medical records system,

students will be more aware of their health status and be motivated to make changes to

improve their BMI levels.

To test this hypothesis, the study could collect data on the BMI levels of students

before and after the implementation of the BMI records system and compare the results to

see if there are any significant improvements.

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SCOPE AND DELIMITATION OF THE STUDY

Scope:

 The study will focus on the development of a medical records system for a specific

school.

 The system will be designed to collect and store data on the BMI of students in the

school.

 The system will be designed to allow school administrators to easily access and analyze

the data for various purposes such as monitoring trends, identifying potential health

issues, and making decisions about nutrition and exercise programs.

 The study will only focus on BMI as a metric for health and will not address other factors

that may impact students' overall health and well-being.

 The study will be limited to the specific school chosen as the subject of the study and

may not be generalizable to other schools or institutions.

Delimitation:

 The study will only focus on the development of a medical records system and will cover

the implementation or evaluation of the system.


 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 8

SIGNIFICANCE OF THE STUDY

Assistant Principal- The assistant principal can only access the medical records of

students and faculty.

Nurse or Clinic Staff- The nurse has the right to encode a record of a students, the nurse

can also access the medical records of students.

Adviser Teacher- The adviser teacher has the right to encode a student medical record

only.

Student - This study helps the student in their future research and also the records of them

in the system.

Future developer - This study can serve as a valuable resource for future developers who

want to develop similar systems and prove patient care. It can also provide insights into the

challenges and opportunities in this field.

Developer - For the developer they can use this study to enhance their skills and also to

develop this system for their study.

DEFINITION OF TERMS

Admin- the activities involved in managing or organizing a business or other organization: I

don't want my best salespeople spending all their time doing admin.

Nurse or Clinic Staff- A person who cares for the sick or infirm. specifically: a licensed

health-care professional who practices independently or is supervised by a physician,

surgeon, or dentist and who is skilled in promoting and maintaining health compare licensed

practical nurse, registered nurse.

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 9

Medical Health Record System - Developers conducted Research to develop this system

use for the school clinic of STIHS.

Cascading Style Sheet (CSS) - The Developers used a CSS for this research to lay out

and arrange the multiple names that need to input in the system CSS can help to edit and

fix on what the client wants to be seen on system.

Electronic Health Records (EHR) - EHR is the based of the Developers on how to make a

system about the medical records developers sited some information about EHR.

Adviser teacher - Adviser teachers in our school system are responsible for encoding

student medical records, and each section has a different adviser teacher assigned to this

task. This has been observed and confirmed through interviews with teachers and school

staff.

Assistant principal - assistant principals were only allowed to view medical reports in our

system that were encoded by the advisers, and they did not have the authority to encode

any records themselves.

Encode - it is the process of collecting, organizing, and entering patient information into

medical record system. This may include students BMI and other relevant health

information.

Module - Developer used a module in the system in any number and distinct to see the

overview of the system.

System - In this research developers built a system to help STIHS in the problem of

organizing of the documents.

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 10

Chapter 2

REVIEW OF RELATED LITERATURE

One of the top priorities for any society is the improvement of the heathcare system.

The total variety of processes need to be streamlined to improve the healthcare system

practices. These upgrades and modifications are necessary to better manage the escalating

costs of healthcare delivery as well as to offer all residents affordable, high-quality

healthcare. Thus, standardizing storage is necessary to offer patients with optimal medical

care upkeep and availability of medical records. Even though scientific discoveries have

substantially enhanced medical treatment in the management of patient information has

improved in recent decades.

Most industries have embraced data automation, but not the health care sector.

Organizations have been slow to convert paper patient records to computers. Examining

and managing patients' health requirements has become increasingly important because of

demand for IT solutions to record clinical data about patients. significant advancements in

electronic healthcare systems can be used to provide patient care. These Systems enable

the collection, organization, and presentation of pertinent clinical data preferable to the way

physical records are kept now. Moreover, in contrast to the paper-Based on records, EMRs

enable simultaneous access to patient records by all caregivers.

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Inadequacy of traditional paper works

Paper records are a good place to start when looking at patient information because

they have several advantages. It is comfortable, transportable, and simple to browse or

scan. Though in the delivery of health care in the current era has several serious flaws.

Paper-based medical records fall short of the requirements of contemporary healthcare

system. It started out as a highly individualized "lab notebook" in the nineteenth century that

doctors employed. They utilized it to jot down their plans and observations so they could:

before the patient's subsequent visit, be reminded of important information.

Although most healthcare facilities use information technology to manage various

aspects systems of patient care are frequently fragmented. Each department in a business.

The hospital has its own computer network. When this occurs, interaction between

departments is reduced to printing and sending information from a single system to another

department's product. These paper documents are eventually transferred to patients'

medical file. Delayed or ineffective patient care is frequently caused by Miscommunication

destroyed or lost documents, and general inefficiencies of paper-based systems.

The adoption of computerized systems can result in significant advances in patient

care. Iteration of the medical records. Thus, the fundamental idea that underpins the

development of health care is reimagines the medical record and lays it forth. The available

and electronic record Both patients and clinicians find it acceptable, secure, and

confidential.
 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 12

A system with the capacity to provide the ability to capture, organize, and more

effectively provide pertinent clinical information. EMR raises the possibility of such

enhanced patient-specific information access. It delivers significant advantages for the

patients' quality of care. The idea of EMR is not new. It has been presented in paper

records in rudimentary form for decades. Additionally, unlike EMRs with paper-based

records enable simultaneous access to the patient record by all caregivers.

Development of computerize health records.

Considering computerizing medical records dates to the early 1960s, when Computer

use originally emerged in hospitals. initially, medical institutions' computers and the support

of financial procedures was emphasized throughout the healthcare system. thus, there

fundamental patient information needed to be recorded to make sure they were accurately

They were charged for the care they received. Given that these systems already have such

fundamental It was only reasonable to expand patient data to incorporate more clinically

pertinent information.

According to (Bmj 328 (7449), 1184-1187, 2014) Many attempts to get clinicians to

use electronic health records have failed, often because of difficulties with data entry. 1–4

Technology should complement and improve clinical care, not impose extra burdens on

already overloaded medical staff. The clinical “usability” of electronic records systems is

particularly relevant with the recent appointment of service providers to implement the

national Integrated Care Record Service for the NHS as usability also affects patient care.
 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 13

I examine important lessons learned from previous attempts to get clinicians to use

computers in health care; discuss how clinicians actually work; make recommendations on

designing or selecting clinical computer systems; and explore how the use of electronic

health.

Efforts are needed to improve PHR data quality through patient-centered user

interface design and standardized patient-generated data guidelines, data integrity through

consolidation of various types and sources, PHR functionality through application of new

data analytics methods, and metrics to evaluate clinical outcomes associated with

automated PHR system use, and costs associated with PHR data storage and analytics.

According to (Journal of the American Medical Informatics Association 18 (2), 181-

186, 2011) Clinical documentation is central to patient care. The success of electronic

health record system adoption may depend on how well such systems support clinical

documentation. A major goal of integrating clinical documentation into electronic heath

record systems is to generate reusable data. As a result, there has been an emphasis on

deploying computer-based documentation systems that prioritize direct structured

documentation. Research has demonstrated that healthcare providers value different

factors when writing clinical notes, such as narrative expressivity, amenability to the existing

workflow, and usability. The authors explore the tension between expressivity and

structured clinical documentation, review methods for obtaining reusable data from clinical

notes, and recommend that healthcare providers be able to choose how to document

patient care based on workflow and note content needs. When reusable data are needed

from notes, providers can use structured documentation or rely on post-hoc text processing

to produce structured data, as appropriate.

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According to (US Patent 8,498,941, 2013) A data security apparatus and method for

controlling access to records provided within automated electronic databases, each record

having an associated set of access rules, comprising: receiving, by a security processor, a

request for access to records associated with at least one of an entity, attribute, and datum

from a requestor; determining a set of records associated with the requested entity,

attribute, or datum, contained in the automated electronic databases; authorizing access to

the records within the determined set of records based on compliance with the associated

set of access rules; defining an economic compensation rule, satisfaction of which is

required for qualification for access to the set of records; selectively permitting access to

records in dependence on satisfaction of the compensation rule; communicating the access

permissions to the host automated electronic databases; and logging the request for

retrieval and a respective access of each record.

According to Rafiqul Islam (2020). Personal Health Record (PHR) is not just the

collection of personal health data but also a personal healthcare and disease management

tool for the individual patient as well as a communication tool with the medical staff.

Moreover, recently PHR has been considered an indispensable tool for patient engagement

in the area of non-communicable diseases (NCDs) and has gained importance. Like many

other developing countries, the growth of NCDs is very high in Bangladesh. Portable Health

Clinic (PHC) system has been developed there with a focus on NCDs and PHR is there

from the beginning. This study for the standardization of PHR system of PHC with the

reference of the PHR proposed by Japanese Clinical Societies could be a reference work

for the national PHR system development in the country.

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According to Hsuan-Yu Chen (2021). With the development of the internet,

applications have become complicated, and the relevant technology has diversified.

Compared with medical applications, the significance of information technology has been

expanding to include clinical auxiliary functions of medical information. This includes

electronic medical records, electronic prescriptions, medical information systems, etc.

Although research on the data processing structure and format of various related systems is

becoming mature, the integration is insufficient. An integrated medical information system

with security policy and privacy protection, which combines e-patient records, e-

prescriptions, modified smart cards, and fingerprint identification systems, and applies proxy

signature and group signature, is proposed in this study. This system effectively applies and

saves medical resources-satisfying the mobility of medical records, presenting the function,

and security of medicine collection, and avoiding medical conflicts and profiteering to further

acquire the maximum effectiveness with the least resources. In this way, this medical

information system may be developed into a comprehensive function that eliminates the

transmission of manual documents and maintains the safety of patient medical information.

It can improve the quality of medical care and indispensable infrastructure for medical

management.

As stated by Martin R Cowie(2017) . Electronic health records (EHRs) provide

opportunities to enhance patient care, embed performance measures in clinical practice,

and facilitate clinical research. Concerns have been raised about the increasing recruitment

challenges in trials, burdensome and obtrusive data collection, and uncertain

generalizability of the results. Leveraging electronic health records to counterbalance these

trends is an area of intense interest. The initial applications of electronic health records, as

the primary data

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages 16

source is envisioned for observational studies, embedded pragmatic or post-marketing

registry-based randomized studies, or comparative effectiveness studies. Advancing this

approach to randomized clinical trials, electronic health records may potentially be used to

assess study feasibility, to facilitate patient recruitment, and streamline data collection at

baseline and follow-up. Ensuring data security and privacy, overcoming the challenges

associated with linking diverse systems and maintaining infrastructure for repeat use of

high-quality data, are some of the challenges associated with using electronic health

records in clinical research. Collaboration between academia, industry, regulatory bodies,

policy makers, patients, and electronic health record vendors is critical for the greater use of

electronic health records in clinical research. This manuscript identifies the key steps

required to advance the role of electronic health records in cardiovascular clinical research.

Reviewing related literature on medical record systems will help you learn more

about the advantages, difficulties, and trends of using these systems. Although there may

not be a direct link between this material and the specific example of recording students'

BMI, it can still be used to help with system design and implementation. The advantages of

using electronic medical record systems, the potential of mobile health technologies, the

potential of artificial intelligence, and the opportunities and challenges of integrating health

information technology into healthcare systems are a few of the key themes that may be

pertinent. Blockchain technology can also improve the interoperability and security of

electronic health record systems.

 POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – CALAUAN CAMPUS Pages

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Synthesis

We described the development of computerized health record systems in this

chapter, care sector then we went over a number of drawbacks that traditional paper-based

systems have medical history. The section also includes a list of several electronic health

records systems, including HER, EMR, and PHRS and how they are related. The

significance of incorporating the different systems is also explored while keeping in mind the

most recent technological advancements.

Medical record-keeping is a critical component of healthcare delivery, and effective

medical record systems are crucial for providing high-quality care, ensuring continuity of

care, and improving research and analysis. However, existing medical record systems face

significant challenges, including fragmentation, inaccuracies, redundancies, and delays in

accessing patient information. Additionally, paper-based record systems make it difficult to

update, access, and share information.

Integrated medical record systems have the potential to address these challenges by

centralizing and standardizing patient information in electronic form. Such systems can

improve the quality of patient care by providing a comprehensive and up-to-date medical

history that is accessible to all relevant providers. Integrated systems can also enhance

administrative efficiency by reducing errors and redundancies, improving data quality for

research and analysis, and reducing costs.

Design and implementation considerations for effective medical record systems

include balancing the need for accessibility, security, and privacy. Additionally, such

systems must consider the diverse needs of various stakeholders, including patients,

providers, administrators, and researchers.