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Die elektronische Fallakte: Arztgeführter, intersektoraler Datenaustausch und Brücke zwischen elektronischen Aktensystemen

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Abstract

Fallakten, Gesundheitsakten, Patientenakten – die Entwicklungen in den letzten Jahren haben eine Vielzahl von Begriffen hervorgebracht. Allen gemein ist, dass sie bestehende papierbasierte Strukturen digitalisieren wollen. Häufig wettbewerblich positioniert, zeigt dieser Artikel ein mögliches Zusammenspiel auf. Der Fokus liegt hierbei auf der elektronischen Fallakte (eFA), welche seit über 10 Jahren ein Konzept zur arztgesteuerten, intersektoralen Kommunikation liefert.

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... Shared electronic health records allow easy access to patient information, a reduced risk of treatment errors, an increased efficiency of professionals, and a reduction of national healthcare costs [13]. The shared electronic health records that currently exist in Germany only serve to transfer files and are case related (e.g., for a hospital to transfer information from the hospital to the general practitioner) [14][15][16]. This existing concept is not sufficient for PPC: professionals want to work collaboratively on documents and have the possibility to view the documentation history of all involved PPC professionals since diagnosis of a life-limiting illness. ...
... The mere exchange of documents that currently takes place through ECHR systems [14,15] is certainly not sufficient in other fields with persons suffering from complex diseases. Therefore, the development of broader ECHRs should emerge based on the insights obtained here and the findings from the needs assessment. ...
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Background: Pediatric palliative care (PPC) patients experience years of multisectoral and professional care. An electronic cross-facility health record (ECHR) system can support the immediate exchange of information among PPC professionals. Based on a needs assessment, a prototype ECHR system was developed. Methods: To evaluate potential users’ perspective regarding the system, a qualitative observational study was conducted consisting of a concurrent think-aloud session and a semi-structured qualitative interview. Results: Twenty PPC professionals (nurses, physicians) from specialized outpatient PPC teams, a PPC unit, and medical offices rated the ECHR system as a helpful tool to improve the exchange and collection of information, communication between PPC professionals, and treatment planning. From the user’s point of view, the basic logic of the ECHR system should be further adapted to improve the interaction of data remirrored from patient records of outpatient and inpatient care with those entered via the system. The users wished for further functions (text search) and content (information on therapies). Some content, such as the treatment process, needs to be further adapted. Conclusion: The developed ECHR system needs to be more specific in some features by offering all available information; while for other features, be less specific to offer a quick overview. The ability to share information promptly and automatically was seen as a tremendous improvement to the quality of care for PPC patients.
Chapter
Situation faced: Digitalization is changing healthcare. Especially hospitals are under tremendous pressure and there is a recognizable difference of digital maturity compared along the European states. Besides German hospitals, Fraunhofer ISST is supporting the Danish Government as they are in an outstanding restructuring process with the aim of building five super hospitals in different regions. The vision, fixed by the Danish DNU Hospital in Aarhus, was to allow the overall vertical and horizontal digitalization of processes by having one common information architecture. Fraunhofer ISST was contracted by DNU to support the definition and valuation of a reference architecture.
Chapter
Zur Verbesserung von Patientensicherheit, Qualität, Rechtzeitigkeit von Interventionen, Effektivität und Versorgungsgerechtigkeit muss die Sektorierung des Gesundheitswesens überwunden und eine patientinnen- und patientenzentrierte Versorgung implementiert werden. Ein wesentliches Instrument hierfür sind einrichtungsübergreifende Elektronische Patientenakten (eEPA), in denen die verteilt erhobenen und gespeicherten Behandlungsinformationen zusammengeführt und sachgerecht den beteiligten Akteurinnen und Akteuren auf Basis eines differenzierten Rechtemanagements zur Verfügung gestellt werden. Struktur und Semantik solcher Aktensysteme müssen in hinreichender Weise die Gegebenheiten der medizinischen Domäne berücksichtigen. Die Funktionalität muss über die reine Verwaltung von Informationen hinausgehen und zum Beispiel das Behandlungsprozess- und Case-Management oder die Entscheidungsfindung unterstützen. Letztendlich sollte eine eEPA auch integriert die Arzt-Patient-Kooperation unterstützen und als Basis für Zweitmeinungseinholungen zur Verfügung stehen.
Article
Efficient communication among doctors who cooperatively support their patients is a prerequisite for implementing effective intersectoral treatment processes. In order to achieve this, IT is becoming increasingly important. With IT systems doctors want to exchange information concerning a patient's case (e.g. doctors' letters, medication prescriptions, etc.). Furthermore, more and more IT-based applications that support the treatment process between patient and doctor (e.g. telemedicine solutions) are being developed. The development of the electronic case record (elektronische FallAkte) has yielded concepts and solutions for a structured case-based information exchange. Furthermore, it has led to infrastructure solutions that support service-based applications for telemedical applications. The "elektronische FallAkte" is an initiative of health institutions that have been organized into the association "Verein elektronische FallAkte". In this paper, concepts and realizations of the "elektronische FallAkte", as well as service-based applications on that infrastructure are described.
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