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The major limitation of most Electronic Medical Record (EMR) solutions currently being implemented in Vietnam is primarily the digitization of data fields in paper medical records following the technical framework of the respective providers and the operational peculiarities of the healthcare facilities involved. Therefore, these EMR systems are still unable to interoperate between healthcare facilities using different providers. Furthermore, these EMR systems operate independently from other health information systems at healthcare facilities. Although some systems utilize internationally recognized standards, the issue of data inconsistency arises when connecting systems with different platforms. Additionally, some crucial clinical data fields for diagnosis and treatment are still in free-text input mode, whereas clinical terminology ensures semantic consistency. Therefore, there is a need for a specific model to consider linking and integrating technical standards and clinical terminologies to enhance the efficiency of exploiting and interoperating EMR. The objective of this paper is to evaluate the implementation outcomes of EMR based on the Health Level Seven Fast Healthcare Interoperability Resources (HL7 FHIR) standard and the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) at Thong Nhat Hospital and Nguyen Tri Phuong Hospital. The proposed integrated model of standardized EMR demonstrates the capability to display and store complete medical records according to the regulations of the Ministry of Health. The testing process involves comparing data fields between actual medical record forms and electronic medical records according to the established data standard to make appropriate adjustments to ensure accuracy and completeness. In addition to validating and reconciling data using objective evaluation tools, the results are also verified by attending physicians and responsible nurses. Data information within the medical records is accurately managed and readily accessible across departments within the hospital, as well as facilitating interoperability in the summary of medical records between the two hospitals according to current regulations.

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Discussion on the Effectiveness of Piloting Electronic Medical Records Based on HL7 FHIR and SNOMED-CT in Hospitals in Vietnam

  • 会议论文

  • 发表日期：

    2025年

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  • Ngoc Nguyen-Chi,
  • Tuan Nguyen-Thanh

摘要

The major limitation of most Electronic Medical Record (EMR) solutions currently being implemented in Vietnam is primarily the digitization of data fields in paper medical records following the technical framework of the respective providers and the operational peculiarities of the healthcare facilities involved. Therefore, these EMR systems are still unable to interoperate between healthcare facilities using different providers. Furthermore, these EMR systems operate independently from other health information systems at healthcare facilities. Although some systems utilize internationally recognized standards, the issue of data inconsistency arises when connecting systems with different platforms. Additionally, some crucial clinical data fields for diagnosis and treatment are still in free-text input mode, whereas clinical terminology ensures semantic consistency. Therefore, there is a need for a specific model to consider linking and integrating technical standards and clinical terminologies to enhance the efficiency of exploiting and interoperating EMR. The objective of this paper is to evaluate the implementation outcomes of EMR based on the Health Level Seven Fast Healthcare Interoperability Resources (HL7 FHIR) standard and the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) at Thong Nhat Hospital and Nguyen Tri Phuong Hospital. The proposed integrated model of standardized EMR demonstrates the capability to display and store complete medical records according to the regulations of the Ministry of Health. The testing process involves comparing data fields between actual medical record forms and electronic medical records according to the established data standard to make appropriate adjustments to ensure accuracy and completeness. In addition to validating and reconciling data using objective evaluation tools, the results are also verified by attending physicians and responsible nurses. Data information within the medical records is accurately managed and readily accessible across departments within the hospital, as well as facilitating interoperability in the summary of medical records between the two hospitals according to current regulations.