eHealth and Clinical Documentation Systems

2020 ◽  
Author(s):  
Petra Knaup ◽  
Nils-Hendrik Benning ◽  
Max Wolfgang Seitz ◽  
Urs Eisenmann
Keyword(s):  
Health Care Professionals ◽  
Digital Health ◽  
Health Data ◽  
International Standards ◽  
Spatial Distance ◽  
Quality Data ◽  
Patient Records ◽  
Clinical Documentation ◽  
Electronic Patient Records ◽  
Aging Societies

eHealth is the use of modern information and communication technology (ICT) for trans-institutional healthcare purposes. Important subtopics of eHealth are health data sharing and telemedicine. Most of the clinical documentation to be shared is collected in patient records to support patient care. More sophisticated approaches to electronic patient records are trans-institutional or (inter-)national. Other aims for clinical documentation are quality management, reimbursement, legal issues, and medical research. Basic prerequisite for eHealth is interoperability, which can be divided into technical, semantic and process interoperability. There is a variety of international standards to support interoperability. Telemedicine is a subtopic of eHealth, which bridges spatial distance by using ICT for medical (inter-)actions. We distinguish telemedicine among healthcare professionals and telemedicine between health care professionals and patients. Both have a great potential to face the challenges of aging societies, the increasing number of chronically ill patients, multimorbidity and low number of physicians in remote areas. With ongoing digitalization more and more data are available digitally. Clinical documentation is an important source for big data analysis and artificial intelligence. The patient has an important role: Telemonitoring, wearable technologies, and smart home devices provide digital health data from daily life. These are high-quality data which can be used for medical decisions.

Medical Narratives and Patient Analogs: The Ethical Implications of Electronic Patient Records

1999 ◽  
Vol 38 (04/05) ◽  
pp. 253-259 ◽  
Author(s):  
E.-H. W. Kluge
Keyword(s):  
Health Care ◽  
Health Care Professionals ◽  
Electronic Patient Record ◽  
Patient Records ◽  
Electronic Patient Records ◽  
Specific Patient ◽  
Patient Profile ◽  
Ethical Implications ◽  
Data Space ◽  
Medical Narratives

AbstractAn electronic patient record consists of electronically stored data about a specific patient. It therefore constitutes a data-space. The data may be combined into a patient profile which is relative to a particular speciality as well as phenomenologically unique to the specific professional who constructs the profile. Further, a diagnosis may be interpreted as a path taken by a health care professional with a certain specialty through the data-space relative to the patient profile constructed by that professional. This way of looking at electronic patient records entails certain ethical implications about privacy and accessibility. However, it also permits the construction of artificial intelligence and competence algorithms for health care professionals relative to their specialties.

Towards a European Health Data Ecosystem

2020 ◽  
Vol 11 (4) ◽  
pp. 884-893
Author(s):  
Nadina IACOB ◽  
Felice SIMONELLI
Keyword(s):  
Digital Health ◽  
National Level ◽  
Healthcare Services ◽  
Health Data ◽  
Data Driven ◽  
Quality Data ◽  
The European Union ◽  
Public Authorities ◽  
Member States ◽  
Research Organisations

The digital health ecosystem is rife with opportunities to improve healthcare through data-driven services in the European Union (EU). The value of health data, in the multiple forms in which they come (from health records to lifestyle data collected by smartphones or wearables), can truly emerge when they are allowed to flow in the ecosystem within a governance framework supported by all relevant stakeholders, with trust as the common and clear thread underpinning it. The coronavirus pandemic has provided an additional impetus for change, showing the importance of coordination and adequate communication between Member States and quality data to inform decision-making. Significant challenges remain, however, in order to achieve a fully integrated European digital health ecosystem, including: (1) the potentially diverging rules set by Member States at the national level and the need for an EU framework for the secondary use of health data; (2) the need for transparency and accountability for sustaining a data-sharing framework involving public authorities, research organisations, industry and citizens; and (3) the need for interoperable data and processes. Taking stock of these challenges, this article puts forward policy recommendations to enable the provision of pan-European data-driven healthcare services and to build a transparent and trustworthy framework for citizens.

scholarly journals Section 2: Patient Records: Electronic Patient Records: Moving from Islands and Bridges towards Electronic Health Records for Continuity of Care

2007 ◽  
Vol 16 (01) ◽  
pp. 34-46 ◽  
Author(s):  
Oliver Bott ◽  
Christian Kohl ◽  
Christian Lovis ◽  
Sebastian Garde ◽  
Petra Knaup
Keyword(s):  
Quality Care ◽  
Health Data ◽  
Semantic Interoperability ◽  
Content Standards ◽  
Patient Records ◽  
Electronic Patient Records ◽  
Data Types ◽  
Use Of Resources ◽  
Patient Will ◽  
Consensus Standard

SummaryElectronic patient record (EPR) systems are increasingly used and have matured sufficiently so as to contribute to high quality care and efficient patient management. Our objective is to summarize current trends and major achievements in the field of EPR in the last year and to discuss their future prospects.Integrating health data from a variety of sources in a comprehensive EPR is a major prerequisite for e-health and eresearch. Current research continues to elaborate architectures, technologies and security concepts. To achieve semantic interoperability standards are developed on different levels, including basic data types, messages, services, architectures, terminologies, ontologies, scope and presentation of EPR content. Standards development organisations have started to harmonize their work to arrive at a consensus standard for EPR systems. Integrating the health care enterprise as a whole will optimize efficient use of resources, logistics and scheduling.The past few years have seen a myriad of developments of EPR systems. However, it is still a long way, until EPR systems can flexibly fulfill all user requirements and an EHR will become broadly accepted. Semantic interoperability will be a key to successful EPR use, especially to avoid double data entries and to better integrate data recording within local workflows. The patient will become an empowered partner, not only by giving him access to his health data. All this will result in enormous quantities of data. Thus, time has come to determine how relevant data can be presented to the stakeholders adequately.

Electronic Patient Records in Medical Practice: A Multidisciplinary Endeavor

1999 ◽  
Vol 38 (04/05) ◽  
pp. 287-288 ◽  
Author(s):  
J. van der Lei ◽  
P. W. Moorman ◽  
M. A. Musen
Keyword(s):  
Medical Practice ◽  
Patient Records ◽  
Electronic Patient Records

Postmarketing Surveillance Based on Electronic Patient Records: The IPCI Project

1999 ◽  
Vol 38 (04/05) ◽  
pp. 339-344 ◽  
Author(s):  
J. van der Lei ◽  
B. M. Th. Mosseveld ◽  
M. A. M. van Wijk ◽  
P. D. van der Linden ◽  
M. C. J. M. Sturkenboom ◽  
...  
Keyword(s):  
General Practitioner ◽  
General Practitioners ◽  
Validation Studies ◽  
Resource Planning ◽  
Routine Practice ◽  
Patient Records ◽  
Postmarketing Surveillance ◽  
Electronic Patient Records ◽  
Use Of Data ◽  
Data Requirements

AbstractResearchers claim that data in electronic patient records can be used for a variety of purposes including individual patient care, management, and resource planning for scientific research. Our objective in the project Integrated Primary Care Information (IPCI) was to assess whether the electronic patient records of Dutch general practitioners contain sufficient data to perform studies in the area of postmarketing surveillance studies. We determined the data requirements for postmarketing surveil-lance studies, implemented additional software in the electronic patient records of the general practitioner, developed an organization to monitor the use of data, and performed validation studies to test the quality of the data. Analysis of the data requirements showed that additional software had to be installed to collect data that is not recorded in routine practice. To avoid having to obtain informed consent from each enrolled patient, we developed IPCI as a semianonymous system: both patients and participating general practitioners are anonymous for the researchers. Under specific circumstances, the researcher can contact indirectly (through a trusted third party) the physician that made the data available. Only the treating general practitioner is able to decode the identity of his patients. A Board of Supervisors predominantly consisting of participating general practitioners monitors the use of data. Validation studies show the data can be used for postmarketing surveillance. With additional software to collect data not normally recorded in routine practice, data from electronic patient record of general practitioners can be used for postmarketing surveillance.

Monitoring, Evaluation, Disease Surveillance, and Quality Improvement

2017 ◽  
Author(s):  
Joia S. Mukherjee
Keyword(s):  
Quality Improvement ◽  
Medical Records ◽  
Disease Surveillance ◽  
Program Planning ◽  
Health Data ◽  
Quality Data ◽  
Electronic Systems ◽  
Health Delivery ◽  
Use Of Data ◽  
Improve Health

Quality data are necessary to make good decisions in health delivery for both individuals and populations. Data can be used to improve care and achieve equity. However, systems for health data management were historically weak in most impoverished countries. Health data are not uncommonly compiled in stacks of poorly organized paper records. Efforts to streamline and improve health information discussed in this chapter include patient-held booklets, demographic health surveys, and the use of common indicators. This chapter also focuses on the evolution of medical records, including electronic systems. The use of data for monitoring, evaluation, and quality improvement is explained. Finally, this chapter reviews the use of frameworks—such as logic models and log frames—for program planning, evaluation, and improvement.

scholarly journals Assessing and piloting interoperability for population health research

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
F Estupiñán-Romero ◽  
J Gonzalez-García ◽  
E Bernal-Delgado
Keyword(s):  
Case Studies ◽  
Population Health ◽  
Health Research ◽  
Network Architecture ◽  
Digital Health ◽  
Data Extraction ◽  
Health Data ◽  
Research Network ◽  
Technical Solution ◽  
Privacy And Security

Abstract Issue/problem Interoperability is paramount when reusing health data from multiple data sources and becomes vital when the scope is cross-national. We aimed at piloting interoperability solutions building on three case studies relevant to population health research. Interoperability lies on four pillars; so: a) Legal frame (i.e., compliance with the GDPR, privacy- and security-by-design, and ethical standards); b) Organizational structure (e.g., availability and access to digital health data and governance of health information systems); c) Semantic developments (e.g., existence of metadata, availability of standards, data quality issues, coherence between data models and research purposes); and, d) Technical environment (e.g., how well documented are data processes, which are the dependencies linked to software components or alignment to standards). Results We have developed a federated research network architecture with 10 hubs each from a different country. This architecture has implied: a) the design of the data model that address the research questions; b) developing, distributing and deploying scripts for data extraction, transformation and analysis; and, c) retrieving the shared results for comparison or pooled meta-analysis. Lessons The development of a federated architecture for population health research is a technical solution that allows full compliance with interoperability pillars. The deployment of this type of solution where data remain in house under the governance and legal requirements of the data owners, and scripts for data extraction and analysis are shared across hubs, requires the implementation of capacity building measures. Key messages Population health research will benefit from the development of federated architectures that provide solutions to interoperability challenges. Case studies conducted within InfAct are providing valuable lessons to advance the design of a future pan-European research infrastructure.

scholarly journals A Roadmap to Inform Development, Validation and Approval of Digital Mobility Outcomes: The Mobilise-D Approach

2020 ◽  
Vol 4 (1) ◽  
pp. 13-27 ◽  
Author(s):  
Lynn Rochester ◽  
Claudia Mazzà ◽  
Arne Mueller ◽  
Brian Caulfield ◽  
Marie McCarthy ◽  
...  
Keyword(s):  
Health Care ◽  
Clinical Trials ◽  
Health Care Professionals ◽  
Digital Health ◽  
Disease Status ◽  
Proximal Femoral Fracture ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Physical Mobility ◽  
High Level

Health care has had to adapt rapidly to COVID-19, and this in turn has highlighted a pressing need for tools to facilitate remote visits and monitoring. Digital health technology, including body-worn devices, offers a solution using digital outcomes to measure and monitor disease status and provide outcomes meaningful to both patients and health care professionals. Remote monitoring of physical mobility is a prime example, because mobility is among the most advanced modalities that can be assessed digitally and remotely. Loss of mobility is also an important feature of many health conditions, providing a read-out of health as well as a target for intervention. Real-world, continuous digital measures of mobility (digital mobility outcomes or DMOs) provide an opportunity for novel insights into health care conditions complementing existing mobility measures. Accepted and approved DMOs are not yet widely available. The need for large collaborative efforts to tackle the critical steps to adoption is widely recognised. Mobilise-D is an example. It is a multidisciplinary consortium of 34 institutions from academia and industry funded through the European Innovative Medicines Initiative 2 Joint Undertaking. Members of Mobilise-D are collaborating to address the critical steps for DMOs to be adopted in clinical trials and ultimately health care. To achieve this, the consortium has developed a roadmap to inform the development, validation and approval of DMOs in Parkinson’s disease, multiple sclerosis, chronic obstructive pulmonary disease and recovery from proximal femoral fracture. Here we aim to describe the proposed approach and provide a high-level view of the ongoing and planned work of the Mobilise-D consortium. Ultimately, Mobilise-D aims to stimulate widespread adoption of DMOs through the provision of device agnostic software, standards and robust validation in order to bring digital outcomes from concept to use in clinical trials and health care.

scholarly journals Electronic patient record and its effects on social aspects of interprofessional collaboration and clinical workflows in hospitals (eCoCo): a mixed methods study protocol

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Marina Beckmann ◽  
Kerstin Dittmer ◽  
Julia Jaschke ◽  
Ute Karbach ◽  
Juliane Köberlein-Neu ◽  
...  
Keyword(s):  
Mixed Methods ◽  
Health Services ◽  
Healthcare Professionals ◽  
Social Research ◽  
Interprofessional Collaboration ◽  
Participant Observation ◽  
Patient Records ◽  
Electronic Patient Records ◽  
Daily Work ◽  
Network Analyses

Abstract Background The need for and usage of electronic patient records within hospitals has steadily increased over the last decade for economic reasons as well as the proceeding digitalization. While there are numerous benefits from this system, the potential risks of using electronic patient records for hospitals, patients and healthcare professionals must also be discussed. There is a lack in research, particularly regarding effects on healthcare professionals and their daily work in health services. The study eCoCo aims to gain insight into changes in interprofessional collaboration and clinical workflows resulting from introducing electronic patient records. Methods eCoCo is a multi-center case study integrating mixed methods from qualitative and quantitative social research. The case studies include three hospitals that undergo the process of introducing electronic patient records. Data are collected before and after the introduction of electronic patient records using participant observation, interviews, focus groups, time measurement, patient and employee questionnaires and a questionnaire to measure the level of digitalization. Furthermore, documents (patient records) as well as structural and administrative data are gathered. To analyze the interprofessional collaboration qualitative network analyses, reconstructive-hermeneutic analyses and document analyses are conducted. The workflow analyses, patient and employee assessment analyses and classification within the clinical adoption meta-model are conducted to provide insights into clinical workflows. Discussion This study will be the first to investigate the effects of introducing electronic patient records on interprofessional collaboration and clinical workflows from the perspective of healthcare professionals. Thereby, it will consider patients’ safety, legal and ethical concerns and quality of care. The results will help to understand the organization and thereby improve the performance of health services working with electronic patient records. Trial registration The study was registered at the German clinical trials register (DRKS00023343, Pre-Results) on November 17, 2020.

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