Electronic health record

Electronic health record

The electronic health record or EHR , English electronic health record , is a planned database in which the medical history , treatment data, medications, allergies and other health data of statutory health insurance sector and falling across which to store the nation's uniform. In German-speaking countries, the eGA is a central pillar of the e-health concepts pursued by industry and health authorities . It is a form of the electronic file . In particular, health data protection is important.

Doctors, dentists, pharmacies and care facilities should be able to access them wherever they are needed without wasting time, provided that the patient, who has sole power of disposal over his files, agrees. The data can be stored centrally or decentrally, depending on the model. Participation should initially be voluntary for all actors. Patients should be able to decide for themselves about the extent and duration of storage.

The design of the state-wide systems is to be regulated by law. The health insurance cards issued by the health insurance companies ( e-card in Austria , eGK in Germany and Switzerland ) and the health professional cards (HBA) should serve as access keys. The goal of the innovation is to be able to control processes and the quality of results in medical treatment procedures. This is where the state-planned systems differ fundamentally from private internet-based offers such as Google Health , HealthVault ( Microsoft ) or Evita ( Swisscom ).

Austria started the national electronic health record called ELGA on January 2, 2014 despite massive criticism.

In Germany, the concept has been researched with regional model tests since 2011.

General

For years, the health care system has been developing in such a way that data is increasingly stored electronically and can also be accessed centrally. An electronic health record (eGA, personal health record PHR) is similar to the electronic medical record of a hospital, a collection of medical data on a person. In addition, in contrast to the electronic patient record ( electronic health record EHR) , the eGA has options for integrating non-medical information (wellness information, diets, physiotherapy advice, ...). It is internet based with minimal client requirements. Only the user has data sovereignty, not a health care institution. According to a complex security concept, he or she can grant other people such as doctors or institutions such as hospitals access to the information (reading and / or writing) or not.

advantages

• Every doctor has all important data quickly available.
• In an emergency, doctors in the hospital can immediately see what previous illnesses a patient has and whether they cannot tolerate certain medications.
• Patients can save and manage medical data independently of the documentation obligation of doctors and dentists in order to improve their information situation in the health care system.
• There are efficiency advantages for insurance companies if referral slips, prescriptions and doctor's letters are electronically issued to the patient in the eGA.
• Statistical processes (big data) can be used to determine accumulations of disease patterns from anonymized health data and, if necessary, preventive measures can be taken.

disadvantage

• Many doctors reject the electronic medical record. They believe that handwritten records are more detailed and contain more relevant details.
• Due to the personal style, relevant information could be extracted more quickly from the handwritten annotations. A study in the British Medical Journal refutes these objections.
• The security procedures developed for the eGA by Gematik GmbH to protect the data (such as cryptographic procedures) are extensive and reduce the number of providers that can be used. The German Medical Association (BÄK) had already requested in 2009 that the data protection of the eGK should also be applied to the eGA.
• Since the patient has the authority to decide which data is saved and which not, the health data in the electronic registration card are only of limited informative value due to the information that is only partially contained. The doctors or dentists calling up the data cannot rely on their completeness and derive diagnostic or therapeutic consequences from this alone.
• Input errors, misdiagnoses or manipulated inputs can lead to incorrect medical conclusions.
• Future desires for the data by politics, health insurance companies, insurance companies or employers cannot be ruled out.
• Data protection, also in terms of medical confidentiality, will have to be regularly adapted to the progress of information technology , otherwise it will not be permanent.

Differences and advantages to other electronic files

In accordance with the treatment contract (secondary contractual obligation), professional law and other legal requirements that come into effect in the context of medical activities, the documentation of treatment measures kept by the treating doctors and dentists must be up-to-date, detailed, error-free and complete as evidence. The ePA usually exists at the doctor or dentist in their clinic or practice EDP system and is maintained and responsible by them as the primary system of their medical documentation. The recordings usually remain protected in the facility's internal local infrastructure, as the doctor and dentist do not expose themselves to the risk of storing them outside their sphere of influence. Every patient can obtain access to their medical files or copies of medical records from their treating physician . It is rarely used in everyday practice. The reason for this is less suspected of lack of interest, but rather the fear of many that the doctor might interpret the request for information as mistrust, which the patient must fear disadvantages in his further treatment.

The main distinguishing feature between the electronic health record and the facility-related, doctor-managed ePA should be the patients' sole power of disposal over their own medical data. The patient alone should decide who saves and changes which data in their files and who is allowed to view and use which information. With the eGA, the patient should be able to follow every treatment process and question it critically in order to be able to actively influence the maintenance or recovery of health.
However, this principle has been softened: Since electronic patient files may be introduced from 2021 without the assignment of rights, every doctor, hospital and pharmacist can view all data in patient files. If, for example, one does not want to reveal psychiatric diagnoses to the dentist, one must not allow these findings to be included in the electronic patient file.

The personal documentation should contain medical case-related documentation as well as self-created content (e.g. own observations, measured values), regardless of whether the patient saves this information himself or has commissioned a doctor to do so. In contrast to the storage of patient data by his treating physician, the patient himself is not subject to the requirement of data economy in Section 3a of the Federal Data Protection Act . He can store any amount of his health and disease information.

Using the example of radiological examinations, unnecessary radiation exposure can be avoided.

The EGA concept faces challenges with regard to ensuring confidentiality, reliability (integrity, authenticity, non-repudiation, completeness) and availability of data.

Interaction of the different file types

Doctors and dentists in private practice have an ePA in their practice EDP. This enables them to document their treatments and, in some cases, communicate directly with medical colleagues electronically, e.g. B. by email. At the same time, a resident doctor can participate in a practice network that jointly manages a virtual EPR. Copies of the medical documentation from the practice EDP are saved there. In addition, the same doctor can also participate in other practice networks or disease-related networks (breast cancer network, diabetes network, etc.), in which a virtual EPR is also kept. This communication is only permitted if the patient has explicitly released the doctor or dentist from his duty of confidentiality for the individual case. There are also doctors and clinics that do not communicate electronically and only document internally. All this distributed information can be controlled by the patient with an electronic health record at least so that it becomes transparent where which information is available.

The concept of the electronic health record takes into account the need for different parallel patient records at doctors and clinics. The eGA can, however, pursue a higher goal in that it represents and integrates the various types of files at doctors and dentists. This makes an important requirement for interfaces to other IT systems (especially to practice and clinic IT systems) for the common exchange of information (i.e. the digital import and export of data).

Legal regulations

United States

The Health Insurance Portability and Accountability Act of 1996, or HIPAA, regulates the electronic processing of patient data in the United States , but not private providers.

Germany

Since 2004, a personal electronic health record (eGA, PHR) according to § 68 SGB V has been a statutory health insurance service. The BVA has been approving statutes since 2005, on the basis of which the software license fees are covered by the health insurance companies. According to § 305 SGB V, legally insured persons have the right to be informed in writing about billed services. According to § 84 SGB X, you can correct, delete or block data.

The " E-Health Act " of 2015 laid the foundation for the introduction of an electronic patient record and an electronic patient box (ePF). The aim should be for insured persons to have constant access to their treatment data and to be able to make them available to the service providers across all institutions. The aim is to give insured persons easy access to their medical data, the electronic doctor's letter, treatment reports and the medication plan. The society for telematics applications of the health card mbH ( gematik ) was obliged according to § 291a paragraph 5c to develop the necessary technical and organizational procedures for a cross-case and cross-facility documentation by December 31, 2018.

According to the Patient Data Protection Act presented in January 2020 as a draft bill , it is up to each patient whether to transfer their data to the electronic health record. In addition to findings, doctor reports or x-rays , the vaccination card , maternity card , yellow examination booklet for children or the dental bonus booklet will also be included in the file from 2022 . Only from 2022 will it be possible to specify in detail who can view which data.

Austria

→ Main article : Electronic health record (Austria)

In Austria, the “Elga” abbreviated health record was developed between 2006 and 2010 and is to be introduced in stages from 2015 to around 2022. Access is administered and controlled via the e-card system. The HL7 standard is the basis for data access . Patients have the option of restricting their use or preventing it entirely via a rejection option (“opt-out” procedure). Despite restrictive access regulations, the card is criticized for promoting the "transparent patient".

Switzerland

→ Main article : Electronic patient record

In Switzerland, it was decided on April 15, 2017 that an electronic patient record (EPD) should be introduced. According to the law, hospitals, rehabilitation clinics and psychiatric rehabilitation clinics are obliged to introduce the EPD by April 2020. Nursing homes and birthing centers have two more years to introduce.

Provider (examples)

Some providers have withdrawn from the market for reasons of cost or demand.

On-line

No special ID cards or reading devices are required for this access.

• Aimedis - Blockchain in healthcare
• Atos IT Solutions and Services GmbH
• Careon GmbH
• Gesakon GbR pilot project (closed user group) from the North Rhine-Westphalian Ministry of Health.
• MGS Meine-Gesundheit-Services GmbH
• vitabook GmbH
• POLAVIS VIVA
• Health Rise GmbH
• Vivy
• IBM Germany GmbH
• DoctorBox
• LifeTime

Online (discontinued)

• ICW AG
• Your doctor24
• Microsoft HealthVault

Offline on USB mass storage

If security concerns or access options for online data are in doubt, the user can also save the data on a USB stick or memory card in the same data format as the online version. However, if this data is lost, it cannot be replaced if there is no further backup. Examples of providers are:

• Ivan Moro There, the medical patient data is encrypted and given access rights so that it cannot be read by others even if the stick is lost. Even after the patient loses the password (but not the USB stick), the data can still be used by healthcare providers with access rights. After the USB stick is lost, the original data is still available from the health care providers and can be saved on a new USB stick if necessary.

Solutions outside the Federal Republic of Germany

• CAMBIO (Sweden)
• Microsoft (UK, US)
• Umedex AG (US, CH, EU)
• A national electronic health record (ELGA) is being developed in Austria with the aim of networking all health service providers. ELGA GmbH, founded in November 2009, is responsible for the implementation. The owners of the non-profit company are federal, state and social security.

See also

• Health data protection
• Informational self-determination
• Medical history
• Patient ID ( allergy pass , blood donation ID , vaccination ID , maternity ID , X-ray pass , etc.)
• Electronic health card
• Electronic Medical Records Adaptation Model (degree of digitization of hospitals)

literature

• Peter Haas: Medical Information Systems and Electronic Medical Records. Springer, 2005, 756 pp., ISBN 3-540-20425-3 limited preview in the Google book search.
• Peter Haas: Electronic patient files - cross-facility electronic patient files as the basis for integrated patient-centered treatment management platforms . Bertelsmann Stiftung, 2017, 288 pages, full text as PDF .

• Frank Warda: Electronic health records. Rheinware, 2005, 270 pages, ISBN 3-938975-00-8 .

Individual evidence

1. ^ Frank Warda: "Electronic health files - possibilities for patients, doctors and industry. Current state of development in Germany". 2005, 300 pages, ISBN 3-938975-00-8 .
2. ↑ E-health strategies: three countries, three ways. Dtsch Arztebl 2011; 108 (11): A-562 / B-457 / C-457.
3. ↑ Criteria catalog for telemedical projects, Federal Ministry of Health (PDF; 144 kB) ( Memento of the original from January 21, 2013 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. . 
4. ^ Austria: Electronic health record decided. Dtsch Arztebl 2012; 109 (48): A-2392 / B-1950 / C-1910.
5. ↑ ELGA health record starts despite massive criticism ( memento from September 27, 2014 in the Internet Archive ), Kleine Zeitung from December 31, 2013.
6. ↑ Electronic patient files: The citizen as “sovereign of the files”. Dtsch Arztebl 2011; 108 (43): A-2295 / B-1936 / C-1916.
7. ↑ J. Hippisley-Cox, M. Pringle et al. a .: The electronic patient record in primary care – regression or progression? A cross sectional study. In: BMJ (Clinical research ed.). Volume 326, Number 7404, June 2003, pp. 1439-1443, ISSN  1468-5833 . doi : 10.1136 / bmj.326.7404.1439 . PMID 12829558 . PMC 162256 (free full text).
8. ↑ Secure transmission procedures. Retrieved March 26, 2020 . 
9. ↑ Concepts and Specifications. Retrieved March 26, 2020 . 
10. ^ HE Krüger-Brand: Electronic health record: More protection needed. In: Deutsches Ärzteblatt. Volume 106, Number 49, 2009, pp. A-2458 / B-2111 / C-2051.
11. ^ The ECPA and Personal Health Record Systems . The Privacy Place. Retrieved May 20, 2013.
12. ↑ § 68 SGB V .
13. ↑ § 305 SGB V .
14. ↑ § 84 SGB X .
15. ↑ WORLD: Internet: Spahn brings the law for electronic patient files on the way . In: THE WORLD . January 30, 2020 ( welt.de [accessed January 31, 2020]).
16. ↑ SR 816.1 Federal Act of June 19, 2015 on the Electronic Patient Record (EPDG). Accessed December 31, 2018 . 
17. ↑ Michael Kaldasch: Aimedis. Retrieved December 2, 2018 . 
18. ↑ Health record .
19. ↑ File online  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.  
20. ↑ HU Prokosch, F. Ückert and others: akteonline.de: patient-oriented health record. In: Dtsch Arztebl. Volume 99, Number 18, 2002. pp. [21].
21. ^ MGS Meine-Gesundheit-Services GmbH | Press release. Retrieved February 22, 2018 . 
22. ↑ Health record
23. ↑ Emergency card
24. ↑ Health app POLAVIS VIVA | Manage your health data. Retrieved on July 20, 2018 (German). 
25. ↑ Use the health portal with health safe online, digitally, mobile and free of charge. Retrieved September 3, 2018 (German). 
26. ↑ Vivy. December 10, 2018, accessed December 20, 2018 . 
27. ↑ IBM Electronic Health Record. April 3, 2019, accessed April 3, 2019 . 
28. ↑ LifeSensor ( Memento from January 6, 2012 in the Internet Archive ).
29. ↑ Medical journal .
30. ↑ IhrArzt24.de ( Memento of the original from September 27, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
31. ↑ PRAXISstick - concept for DE, AT, CH and FL, as well as SK and CZ. iglware.com
32. ↑ Omni .
33. ↑ ELGA GmbH .