The electronic record: A win-win situation for everyone

Previous illnesses, lab reports, known allergies, medications — if all of a member’s major health information is available in digital form and can be accessed from a central platform when treatment is needed, everyone involved benefits immensely.

Bureaucracy and paperwork chaos are greatly reduced, and efficient structures bring cost savings at many levels. But the members benefit the most: In many cases, people can be treated much more quickly and effectively than in the past. Informed patients will someday find that their self-administered electronic patient record has become as much a part of their identification as a personal identity card or driver’s license.

Greater security with the record

Modern hospitals can no longer manage without digital documentation of patient data. It facilitates patient care because the information is available quickly and simultaneously at multiple locations within the hospital. It is also unambiguous: Data cannot be misread, which can happen with something like an analog temperature chart. The wrong medication could be given because of an illegible handwritten entry. Using various subsystems, such as electronic medication management, overdosage and harmful interactions between different drugs can be avoided. This makes subsystems an ideal supplement to the central HIS programs. The low level of integration with other programs to date — such as the patient data management system (PDMS) — represents a challenge. With the increase in cross-sector collaborations, interoperability has become more and more important in our hospital. We have therefore adopted the IHE standard for data exchange and are building an IHE platform. Electronic health records can also be linked to the platform, for example as part of the emergency room triage process.

Benefits for the patient

Knowing what is in previous reports and what medical data is already on record is extremely helpful, particularly in the case of patients who cannot provide information themselves because of an injury or illness. This significantly improves patient safety levels. In addition, clinicians today are already as comfortable with electronic patient records as they are with stethoscopes and scalpels. If they can also use digital systems for quick access to reference literature, patients will see tangible benefits from greater speed and accuracy in diagnosis and treatment. Even second opinions, which are often requested, can be stored in the electronic record and accessed when needed.

Electronic patient records are the most important control mechanism for efficient patient management as we move toward the paperless hospital. For example, the radiology department of the BG Trauma Hospital in Berlin has been completely digital since it opened in 1997. This strategy is supplemented with useful modules such as “mobile ward rounds,” which allows physicians, nursing staff, and therapists to access and document information within the same system. This type of system also allows for optimal patient integration. Patients have bedside access to their data, including radiology images and reports, and can immediately be fully informed.

Patients will see tangible benefits from speed and accuracy in diagnosis and treatment.

 

Increasing acceptance

Patient receptiveness to electronic data processing is already increasing in our progressively more computerized world. Even now, 30 percent of patients do Internet research before a doctor visit, and 40 percent do so afterward — regardless of whether they are seeing a hospital-based or private-practice physician. The doctor-patient relationship will barely be affected by the electronic record. There is still no digital service better than advice from an experienced physician. However, many patients have concerns that need to be taken seriously with respect to data protection and potential misuse of highly personal, intimate information. Repeated attempts by criminals to access patient data in hospitals, medical practices, and other treatment facilities — most of which are fortunately unsuccessful — also help to foster mistrust. It is imperative to protect health data by means of suitable technological systems, with the General Data Protection Regulation providing transparency: Each patient gets to determine who is allowed to see which information, and who can access which documents. Many patients are not yet accustomed to this kind of careful management of their personal data, but I feel certain that over time, more and more people will become more proficient at managing their data and permissions for transfers.

 

 

Policymakers are paying attention

Politicians also took a long time to fully grasp the significance of the digital world. It makes me all the happier to see that digital growth is now being promoted at many levels. In the Chancellor’s Office, Dorothee Bär acts as the government’s Digitization Minister. Jens Spahn, the Minister of Health, brought in recognized digital expert Gottfried Ludewig as a department head, and the other ministers are also aware that they need to catch up to other countries and industries. Launching a nationwide electronic patient record is a significant step toward closing the gap with other countries — at least in the healthcare field.