[The national GTH haemophilia registry as database within the scope of the German human genome project]. / Das bundesweite GTH-Hämophilie-Register als Datenbasis im Rahmen des Deutschen Human-Genom-Projekts.

The Committee of Haemophilia of the GTH has established a central registry for all German centers treating patients with haemophilia. The intention was to establish a suitable system for collecting and analyzing epidemiological data relevant to bleeding disorders. The registry provides the database within the scope of the German Human-Genome-Project. The set goal is the complete molecular characterization of the genetic mutations on chromosome X of haemophilia A patients in Germany and subsequent correlation with the phenotype. An electronic network is applied for communication. A Java-application was developed for online electronic data acquirement by the participating centers. Offline data entry and sending encrypted data carriers is possible, too. A high level of security is assured by personalized access. Data are anonymized and scrambled by secure encoding. The concept was confirmed by the official data security offices. A considerable improvement for the epidemiological sciences and a better basis on therapy for patients with bleeding disorders is expected. Furthermore the registry is available for other scientific projects.

[Improving productivity by implementing RIS and PACS throughout the clinic: a case study]. / Produktivitätsverbesserung durch klinikweite RIS und PACS: eine Fallstudie.

PROBLEM: How are improvements in productivity in connection with RIS/PACS to be defined? What do they cost? To limit the problem to the relevant topics, we first describe the objectives of a radiology department and the identified bottlenecks in the workflow. How to define and assess the improvements is discussed. METHODS: The case in question for this study is the RIS/PACS project at the "Klinikum der Universität München, Campus Grosshadern". The goals of the project and its present status are reviewed. The project is not yet completed, so this is a "midterm" report. RESULTS AND DISCUSSION: We describe the status of the achieved and not yet achieved goals and of the eliminated bottlenecks. On the plus side, for example, nearly 100% of all digitally generated images (except mammogramms) are digitally archived. They are accessible to the same percentage in radiology via PACS and in the hospital via the webbased intranet image distribution system when needed. In some radiology areas, such as multislice CT, already the reporting can no longer be performed without softcopy image interpretation. However, the full elimination of hardcopy images is still not reality, since the distribution to DICOM viewers for selected requesters with demands for almost reporting quality, high cost image displays is still in the testphase. To reduce film costs, images are being printed on a high resolution paper printer in addition to the intranet distribution during this transition period. On the negative side, due to a lack of job positions in the transcription rooms, about 40% of the reports are still being handwritten by radiologists. Furthermore, the dictated and transcribed reports are usually still not available early enough in the RIS and thereby in the intranet report distribution of the hospital. Here only a speech recognition system can remedy the situation. As soon as this problem is solved and the image distribution to the DICOM viewers works routinely, the reports and the images will be accessible within minutes to maximally within some hours after the examination. CONCLUSION: The goals reached so far suffered delays due to unforeseen problems and pitfalls. Altogether, a quieter operation and workflow in radiology has already been achieved, due to less inquiries from the requestors for unfinished examinations, images and/or image copies.

[University clinics as centers of radiologic performance alliances in the ambulatory and inpatient sector]. / Universitätskliniken als Zentren radiologischer Leistungsallianzen im ambulanten und stationären Sektor.

PROBLEM: Health care delivery in Germany has to face severe challenges that will lead to a closer integration of services for in- and out-patients. University hospitals play an important role due to their activities in research, education and health care delivery. They are requested to promote and evaluate new means and ways for health care delivery. METHODS: The Institute of Clinical Radiology at the University Hospital of the Ludwig-Maximilians-University started teleradiological services for hospitals and general practices in January 1999 in the framework of the "Imaging services--teleradiological center of excellence". Legal, technical and organizational prerequisites were analyzed. RESULTS: Networks between university hospitals and general practices are not likely to solve all future problems. They will, however, increase the availability of the knowledge of experts even in rural areas and contribute to a quality ensured health care at the patients home. Future developments may lead to international co-operations and such services may be available to patients abroad. CONCLUSION: Legal, technical and organizational obstacles have to be overcome to create a framework for high quality telemedical applications. University hospitals will play an important role in promoting and evaluating teleradiological services.

[Quality assurance of medical information in the internet--challenges for a seal of approval in gynecology]. / Qualitätssicherung medizinischer Informationsangebote im Internet - Möglichkeiten eines Gütesiegels für die Gynäkologie.

The Internet offers a vast amount of medical information for laymen and experts. Many sites focus on gynecology and obstetrics. The multitude of information and lacking structure make it difficult to retrieve high-quality information and to distinguish them from dubious ones. Many projects were started to solve these challenges. Criteria for assessing medical information on the internet were published by several authors. Some information providers comply to such standards voluntary to show their quality standards. There are scientific councils who assess individual sits. The Concerted Action on Health Information Systems (Aktions forum Gesundheits informations systeme AFGIS) was founded by the German Federal Ministry of Health to coordinate existing activities. The knowledge of experts is essential to describe and rate internet resources. The cooperation of the scientific medical societies in Germany should be an aim to make a quality seal for information on gynecology and obstetrics possible.

[E-mail in plastic surgery--a useful addition to current communication possibilities?]. / E-mail in der Plastischen Chirurgie--Eine sinnvolle Ergänzung bestehender Kommunikationsmöglichkeiten?

The internet is a global network of computers with a broad variety of services and options. It offers completely new ways of communication and investigation. At present, this new medium seems to be the final technical revolution in communication. It presents new dimensions which were utopia so far. Electronic mail (e-mail) is the most frequently used service within the internet. For a plastic surgeon it seems to be the fastest and the most cost-effective way of transferring data of any kind. The aim of this paper is to critically assess the transfer of confidential data via e-mail as well as to present general conditions for the use of e-mails. Therefore, our own experiences made with this technology are described to point to the possibilities, but also to indicate problems and weaknesses of this medium. Some rules should be obeyed for the transfer of confidential patient data via e-mail in order to satisfy the demand for data-security standards. Also medicolegal aspects must be considered. These recommendations or rules and aspects will be discussed to offer a guideline to plastic surgeons for their e-mail applications.

Communication in plastic surgery by means of e-mail: experiences and recommendations for clinical use.

The Internet is a global network of computers with a broad variety of services and options. Electronic mail (email) is the most frequently used service. For a plastic surgeon, this mode is the fastest and the most cost-effective way of transferring data of any kind. The critical aim of this study was to assess the transfer of confidential data by means of e-mail and to present general conditions for the use of e-mail. Therefore, experiences with this means of communication are described to point to the possibilities, but also to indicate problems and weak points of this medium. Some rules should be obeyed for the transfer of confidential patient data by means of e-mail to satisfy the demand for data-security standards. Also, medicolegal aspects must be considered. These recommendations or rules and aspects will be discussed to offer a guideline to plastic surgeons for their e-mail applications.

Quality assurance of medical information on the Internet.

Physicians and Laymen use the Internet to answer health related questions. The quality of information is very diverse between the various web sites. Quality assurance is lacking. However, there are several means to rate the quality of information on the internet. For the time being, these mechanisms show some evidence on the provided information. Quality assurance, like peer review for scientific papers, has to be established to make the internet a trustworthy resource for physicians and patients.

Design elements for a computerized patient record.

Computerized medical record systems have to present user- and problem-oriented views of a patient record to health-care professionals. Presentation and manipulation of data must be easily adaptable to current and future demands of medical specialties and specific settings. During the definition, development and evaluation of a prototype of a computerized patient record system, design elements were elaborated to support physicians and other health-care professionals. Our approach shows a high degree of flexibility and adaptability to specific needs, problem orientation and connectivity to other systems, via a hospital information network. The explicit description of the contents of a patient record allows to augment the number of items that can be recorded without modifying the data structure. New views on patient data can be added to the system without interfering with the routine use of the system. Application in several medical specialties proved the feasibility of our prototype.

Surgical versus medical care for postoperative cardiac surgical patients at the general ward.

OBJECTIVES: To shorten hospital stay after cardiac surgery, several risk factors have been defined to identify patients who can be discharged early. These risk factors are dependant on the patient; no studies exist on the influence of the treating physician himself on postoperative patient stay. METHODS: In a university affiliated cardiac surgical clinic we investigated patients who were postoperatively treated either on medical wards with no cardiac surgeon's presence or on a cardiac surgical ward; at both types of wards physicians had several years experience with cardiac surgical patients. Taking several risk factors for postoperative morbidity into account, postoperative length of stay and incidence of wound healing complications have been compared. RESULTS: Within a 3-month period, 84 patients were treated at the cardiac surgical ward, 102 patients at the medical wards. Risk factors for postoperative morbidity were present in 87% of patients, statistically independent of postoperative wards. Although demographic data and median ICU-stay of both patient groups was comparable, the median post-ICU stay was 9 days at the surgical and 13 days at the medical wards (P < 0.0001). Incidence of wound healing complication was higher (19.6%) at the medical wards than at the surgical ward (10.7%), without reaching statistical significance. CONCLUSION: As patients at the respective wards were statistically not different, the difference in post-ICU stay, infection and costs must depend on the treating physicians. As a consequence, postoperative care for cardiac surgical patients in all cases should include direct cardiac surgical participation.

Evaluation of medical internet sites.

A huge amount of medical information is available on the Internet for both experts and laypersons. These resources are frequently used to answer current medical questions and are thus likely to influence the behavior of the users. Criteria for assessing the quality of medical Internet resources have been established by a number of authors and institutions to provide reliable medical information on the Internet for both patients and physicians. Clinical studies on the impact of information on the Internet are still lacking. The next step is to evaluate the outcome of such information services and to prove that they affect health-related parameters. Due to different constraints, classical strategies of controlled clinical trials can only be partly applied. New methods have to be developed and validated in practice.

[Uniform access to clinical data in a distributed system. The radiology example]. / Einheitlicher Zugriff auf klinische Daten in einem verteilten System. Beispiel Radiologie.

PURPOSE: Providing medical reports onwards and ambulatory settings in electronic form can improve the quality of health care delivery. Radiology was chosen as an example to demonstrate how to implement uniform access to clinical data in a hospital. METHOD: Medical professionals at the university hospital in Munich, Grosshadern, have access to all radiological reports of their patients. Web browsers are used as a front end. A centralized administration of users and patients is in place. RESULTS: Centralized access control and patient selection guarantee uniform access to all applicable data via intranet and controls access rights. The high acceptance of this service is reflected by the high number of 150 requests per day. DISCUSSION: Access to radiological reports within the Grosshadern University Clinics was enabled via web browsers in a short time. The high acceptance of the system also proves its easy use. Integration of the system in a centralized user and patient identification system supports the unified access to clinical data.

[Aspects of electronic patient records in radiology]. / Aspekte der elektronischen Krankenakte in der Radiologie.

PURPOSE: The computerized patient record must provide patient- and problem-oriented access to all relevant patient data for health care professionals. The aspects of such systems will be analyzed in the light of the radiologist's needs. METHODS: Integration of the computerized patient record in a hospital communication network allows automated data exchange with the ancillary systems. Accessibility of electronic textbooks supports case-based learning during routine work. RESULTS: The computerized patient record not only supports routine clinical tasks but also training, education and research. The workflow in a hospital can be supported by the computerized patient record. Studying the tasks of a radiology department shows that both clinicians and radiologists will benefit from such a system. DISCUSSION: Current implementations of clinical computerized workstations offer only a fraction of these features. Advances in technology and increasing demands at the point of care will promote the development of new information systems of this kind.

[Filmless documentation and image distribution to referring physicians exemplified by a radiologic community practice]. / Filmlose Befundung und Bildverteilung an Zuweiser am Beispiel einer radiologischen Gemeinschaftspraxis.

In healthcare, cost effectiveness as well as the quality of examinations and procedures are subjected to quickly increasing expectations and demands: we like to demonstrate how the resulting challenges and problems can be met with implementation of modern information technology. Analysing the respective demands (pattern of quantities) and choosing the adequate technical solution/technical approach, we found filmless reading and the usage of digital image distribution to communicate with referring physicians to be cost effective as well as of higher quality. Special attention should be paid to the rigorous maintenance of data security and access. Today's information technology allows individual adjustment to the respective size and requirements of a radiological department or practice for filmless reading and digital image distribution. Working with the systems as a matter of routine and using all of the expanding technological possibilities, an important improvement of service and quality can be achieved. Amortisation will be obtained despite high investments, due to the subsequent savings in personal- and enterprise costs.

Functional requirements for a HIS-RIS-PACS-interface design, including integration of "old" modalities.

Radiology, Information Systems (RIS) and Picture Archiving Systems (PACS), have the potential for immense rationalization of operations in radiology and hence for the improvement of health care, as well as the return of investments. These systems must, however, be carefully designed such that they support routine work rather than being an additional burden to radiology staff. Analyses show that comprehensive communication of patient demographic and clinical data between RIS, PACS and Hospital Information Systems (HIS) are necessary prerequisites to achieve cost effectiveness. Based on analyses of radiology operations in a large university primary care hospital, functional requirements and data structures for designing HIS/RIS/PACS interfaces are presented. These concern communication of past examinations, associated written reports and images, appointment scheduling, requests of new examinations, digitizing old analog X-ray films, access from RIS/PACS to other clinical data, and transfer of new radiology reports and relevant images. Consistency of all redundant data stored in the three systems is essential. A pragmatic, safe and inexpensive method of electronically integrating "old" modalities not fully "PACS capable" in the HIS/RIS/PACS world is presented.

[The filmless hospital--a legal challenge]. / Das filmlose Krankenhaus--eine juristische Herausforderung.

PURPOSE: This article concerns the legal aspects of digital archiving of radiological images, in particular with regard to the resolution passed by the 37th Committee meeting of the Federal Board of "RöV" (x-ray ordinance). Concepts of filmless hospitals must therefore be tested for compliance with all present legal requirements. MATERIAL AND METHODS: The literature concerning the legal aspects of digital medical archiving of x-ray documents is reviewed. The concept of a digital archive was compared with these aspects and tested for compliance with the respective legal rules. RESULTS: There are no legal obstacles to realizing our concept of a filmless hospital. However, there are no civil court rulings on record, since there have not been any legal proceedings to date. CONCLUSIONS: There are no legal objections to a complete digital archiving in a hospital in the absence of any court rulings to the contrary.

[Evaluation of medical Internet sources: outcome]. / Evaluation von medizinischen Internetressourcen: Outcome.

A large number of medical information is available on the Internet for laymen as well as for medical experts. This is used to answer medical questions in concrete situations and is likely to influence health related behaviour directly. Therefore the questions arises how health is affected and how the effects can be measured. The classical way of performing clinical studies can be applied to the Internet only in part. New methods must be developed and evaluated in individuals studies.

[Evaluation of medical internet resources: quality criteria]. / Evaluation von medizinischen Internetressourcen: Qualitätskriterien.

Quality Criteria: On the Internet medical information is provided for laymen as well as for medical experts. This is frequently used to answer specific medical questions and is likely to exercise a direct influence on health related behaviour. Several authors and institutions set up quality criteria for medical information resources on the Internet to establish a basis for a reliable service to patients and physicians. Existing information resources can be evaluated according to these criteria.