Affiliations: Oficina de Innovación de Sistemas de
Información Sanitaria, Fundación Marqués de Valdecilla,
Consejería de Sanidad y Servicios Sociales, Spain | Servicio de Medicina Preventiva. Hospital
Universitario Marqués de Valdecilla, Santander, Spain
Note: [] Corresponding author: Javier Carnicero, Director de la Oficina
de Innovación de Sistemas de Información Sanitaria, Hospital
Santa Cruz, 4^a planta; Barrio Las Mazas, 17; 39120,
Liencres (Cantabria), Spain. Tel.: +34 942 315183; E-mail:
jcarnicero@humv.es
Abstract: The application of Information and Communication Technologies to
clinical activity gives rise to electronic health and clinical records. In this
way clinical information comes to take part in a health information system and
is a source of data for the management of knowledge, epidemiology and health
care planning. The primary consequence of the electronic health and clinical
record is the improvement in continuity and quality of health care. This essay reviews the requirements for the electronic health and
clinical record (identification of persons, integration of information and
compliance with the norms of security and confidentiality). It also summarises
the consequences of using the electronic health and clinical record: the
improvement in continuity and quality of health care as well as the greater
availability of clinical information as a source of knowledge. Special mention
is made of the opportunity to enhance the clinical management of medicinal
products (prescription, dispensing and evaluation); this, too, benefits from
the electronic prescription, provided that this is considered a clinical
document closely connected to the electronic clinical record.
