eHealth 2015 Special Issue: Impact of Electronic Health Records on the Completeness of Clinical Documentation Generated during Diabetic Retinopathy Consultations.

BACKGROUND: Two years ago, the Diabetic Retinopathy (DRP) and Traumatology clinic of the Department of Ophthalmology and Optometrics at the Medical University of Vienna, Austria switched from paper-based to electronic health records. A customized electronic health record system (EHR-S) was implemented. OBJECTIVES: To assess the completeness of information documented electronically compared with manually during patient visits. METHODS: The Preferred Practice Pattern for Diabetic Retinopathy published by the American Academy of Ophthalmology was distilled into a list of medical features grouped into categories to be assessed and documented during the management of patients with DRP. The last seventy paper-based records and all electronic records generated since the switch were analyzed and graded for the presence of features on the list and the resulting scores compared. RESULTS: In all categories, clinical documentation was more complete in the EHR group. CONCLUSIONS: In our setting, the implementation of an EHR-S showed a statistically significant positive impact on documentation completeness.

The strategic approach of managing healthcare data exchange in Austria.

OBJECTIVES: The exchange of electronic medical data between healthcare providers constitutes an integral part of modern medicine, and its importance is growing. Efficient application on a national level requires a uniform approach to the management of healthcare data exchange, avoiding isolated solutions that are expensive and also incompatible. METHODS: In this communication we explain the basic concepts of establishing a nationwide framework to guide healthcare data exchange in Austria. To achieve this goal, a three-step approach was adopted: (i) creating general guidelines to direct electronic medical data exchange; (ii) defining detailed standards for electronic messages; (iii) organizing pilot projects to implement these standards, and further improving the general guidelines based on the results of the pilot projects. RESULTS: We present the MAGDA-LENA framework which guides healthcare data exchange in Austria, and compare it with the US framework HIPAA. We describe several communication scenarios for which concrete message standards were developed in recent years, based on the MAGDA-LENA framework. We further discuss the implementation of these standards in four pilot projects. CONCLUSIONS: The strategic approach of managing healthcare data exchange presented in this paper is expected to have a substantial impact on medical informatics in Austria over the next few years.

ArchiMed: a medical information and retrieval system.

ArchiMed is a highly flexible medical data storage and retrieval system which adds sophisticated clinical research support to a standard hospital information system (HIS). Currently, the HIS of Vienna General Hospital-University Hospital (2000 beds) stores the clinical data of over 2 million patients. While this system supports patient care (e.g., ADT, clinical chemistry, diagnosis, procedures), it has no features to facilitate research, such as the management of clinical studies. ArchiMed is designed to support clinical research. It includes an independent database, which mirrors virtually all the information held in the HIS while also allowing new data to be collected independently and to be added to the database. Flexible retrieval and analysis of data contained in the database are then possible. Thus, existing patient data can be smoothly incorporated into a study together with data collected specifically for research purposes. The system has already been successfully installed in the departments of surgery and soon in other departments as well.