A healthy health service
Up-to-date, complete, sound medical documentation is a vital requirement for hospital financing. Funding organisations require the hospital management to produce full documentary evidence in a transparent way for services provided in connection with diagnoses and case complexity. The introduction of DRGs and the increased requirement for better quality are forcing more and more hospitals and clinics to reorganise their internal operational procedures and to gear themselves to commercial and corporate objectives.
The cost pressure in the health service requires careful management of resources – especially the precious time of doctors and nurses. In the future, hospitals will be faced with the make-or-break challenge of continuous quality improvement and economic efficiency. The apparent contradiction between the need to make savings and to improve quality can be resolved with the right information management technology.
Modern electronic patient records may soon replace paper patient files in hospitals. Until now only about 2% of hospitals and approximately 15% of GPs have introduced such an electronic record system – but they are spreading fast. The electronic patient record will soon be standard in clinical practice. The advantages are obvious: there will be an end to many unnecessary duplicate examinations, the doctor can identify incompatible medicines more easily. The patient does not have to retell his medical history for the umpteenth time and both can concentrate on the progress of treatment.
The scope, quality and availability of information are critical for optimum provision of support for the processes. Consequently, the electronic patient record in the DOXiS4 iECM Suite provides efficient, electronic archiving with continuous availability of all stored data or documents in the electronic patient record or in clinical workstation systems.
Precious time is saved whenever test results or information from previous treatment do not have to be copied. For example, results or x-ray photographs brought can be scanned at the time of admission and inserted into the electronic patient record. Consequently, the doctor in charge not only has the documents relating to previous treatment on the premises, but also the full medical history on the screen.
The archive as the hospital's memory
Archiving documents and providing electronic patient records on request are now a necessity, but this does not go far enough. To obtain the benefits that create added value, hospitals need to be able to make use easily of the knowledge held implicitly in the DOXiS4 archive. As the hospital's memory, the archive has a strong knowledge function and is not used as a mere storage system. It functions as a knowledge base and its content must be secured and incorporated into the hospital’s daily work and decision-making processes.
The data of the current medical care or administrative processes is integrated seamlessly into the digital archive. The contents of structured data (databases) and unstructured data (documents, images etc.) are combined in the electronic patient records.
The patient record has a very special importance in practice. Not only does it contain very confidential data, the patient record is frequently also the basis for doctors' decisions which can be a matter of life and death. The faster the patient's full history is available and the more comprehensively the doctor can retrieve comparable medical histories, the greater the prospects of a cure. The electronic record is vastly superior in this respect to the conventional file or microfilm.
Replies to medical questions
Evidence-based medicine (EBM) is the appropriate use of scientific evidence in the medical care of patients. EBM, clinical expertise and patients' wishes are the decisive factors for medical decision-making. That is why the need to provide answers to medical matters in an efficient and cost-effective way is becoming a more prominent issue.
Until now it has been common to search through specialist literature using Boolean methods or fuzzy logic in full-text systems. However, this method involves searching for keyword combinations and not for content or associations. Although the quantity of information in databases and on the internet is increasing all the time, the conventional search methods often fail to produce satisfactory results.
Optimum support for medical decision-making is provided here with the intelligent, associative full-text search and the options of content-based, learning classification. Connections and content consisting of unstructured documents are identified, developed and classified.
Subsystems from a diverse range of providers are now used in hospitals. The challenge is to bring about smooth integration of all systems involved to form an overall solution. SER combines all the individual solutions in an overall IT concept. Different managerial, medical and case-based views are supported by the integrative approach to electronic patient records provided by SER’s DOXiS4 iECM Suite.
From admission to discharge
SER’ electronic patient record guarantees comprehensive, process-oriented support for medical, care and administrative processes – from admission to discharge. Mapping of work processes and selectable views for patients facilitates specialised presentation of information at any time. Completed treatment cases can be retrieved again quickly and easily. All stored information is available at any time in a full, structured and manageable form and can be retrieved with any search criteria.
Staff involved in treatment have an overall view of the patient information. Fast and safe navigation as well as quick location of individual documents are very important issues. Stored items such as x-ray images, photos or video recordings can be shown in parallel on the screen. Data from connected IT systems, e.g. from management, the x-ray department or a laboratory are imported automatically after completion and immediately assigned to the electronic patient record. Results become part of the electronic patient record and they can be seen by authorised persons at the same time throughout the medical establishment.
The correct assignment of results and multi-media documents relating to results takes place in the electronic patient record. Existing physical records (e.g. paper files, video tapes, microfilm etc.) can likewise be managed as an element of the electronic patient record. Instead of displaying objects directly on the screen, you can see whether the relevant object is available in the physical archive or if it is currently on loan (record management).
Find out more about SER's healthcare provision on the dedicated website www.lenus.info.
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