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. 2004 Aug 24:2:Doc06.

An electronic health record to support patients and institutions of the health care system

Frank Uckert  1 , Marcel Lucas Müller, Thomas Bürkle, Hans-Ulrich Prokosch
Affiliations

An electronic health record to support patients and institutions of the health care system

Frank Uckert et al. Ger Med Sci. .

Abstract
in English, German

The department of Medical Informatics of the University Hospital Münster and the Gesakon GmbH (an university offspring) initiated the cooperative development of an electronic health record (EHR) called "akteonline.de" in 2000. From 2001 onwards several clinics of the university hospital have already offered this EHR (within pilot projects) as an additional service to selected subsets of their patients. Based on the experiences of those pilot projects the system architecture and the basic data model underwent several evolutionary enhancements, e.g. implementations of electronic interfaces to other clinical systems (considering for example data interchange methods like the Clinical Document Architecture - standardized within the HL7 group - and also interfacing architectures of German GP systems, such as VCS and D2D). "akteonline.de" in its current structure supports patients as well as health care professionals and aims at providing a collaborative health information system which perfectly supports the clinical workflow even across institutional boundaries and including the patient himself. Since such an EHR needs to strictly fulfill high data security and data protection requirements, a complex authorization and access control component has been included. Furthermore the EHR data are encrypted within the database itself and during their transfer across the internet.

Im Jahr 2000 initiierten das Institut für Medizinische Informatik und Biomathematik der Universität Münster und die Gesakon GmbH ein Kooperationsprojekt zur gemeinschaftlichen Entwicklung einer Elektronischen Gesundheitsakte (EGA), genannt „akteonline.de". Seit 2001 wurde diese EGA bereits von verschiedenen Kliniken des Universitätsklinikums Münster bestimmten Zielgruppen aus ihrem Patientengut als zusätzlicher Service im Rahmen verschiedener Pilotprojekte angeboten. Aufbauend auf den Erfahrungen dieser Pilotprojekte wurden die zugrunde liegende Systemarchitektur und das Datenmodell mehreren evolutionären Weiterentwicklungen unterworfen. Unter anderem gehörte dazu das Design von Schnittstellen zu anderen medizinischen Informationssystemen (hierfür wurden sowohl der von der HL7-Gruppe definierte Standard der „Clinical Document Architecture (CDA)" als auch die in deutschen Arztpraxissystemen vielfach schon etablierten Lösungen wie VCS und D2D berücksichtigt). "akteonline.de" unterstützt zurzeit sowohl Patienten als auch Gesundheitsbetreuer und hat es sich zum Ziel gesetzt, als „collaborative health information system" diagnostische und therapeutische Prozesse auch sektorübergreifend und selbst den Patienten unmittelbar einbeziehend zu unterstützen. Aufgrund der hohen Sensibilität der in einer solchen EGA zu speichernden Patientendaten wurde eine umfangreiche Autorisierungs- und Zugriffregelungskomponente implementiert. Zusätzlich werden die Daten der EGA sowohl während ihres Transports über öffentliche Netze als auch in der Datenbank selbst verschlüsselt.

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Figures

Figure 1
Figure 1. View of a patient's medication record in akteonline.de.
Context sensitive links like the shown "search in several internet search engines" to access further drug information for a selected drug have been established.
Figure 2
Figure 2. Detailed view of a multimedia data object (in this example DICOM radiology images) with thumbnail preview within akteonline.de.
Figure 3
Figure 3. Dividing a referral letter into the different CDA fields in order to establish a standardized data input interface for akteonline.de
Figure 4
Figure 4. TANs can be generated and printed from the "settings menu" of akteonline.de.
Predefined access profiles are associated which each TAN.
Figure 5
Figure 5. Screenshot 1 illustrating the exchange of lab results from the HIS to the EHR
Figure 6
Figure 6. Screenshot 2 illustrating the exchange of lab results from the HIS to the EHR
Figure 7
Figure 7. Screenshot 1 illustrating the exchange of referral letters between the HIS and the EHR
Figure 8
Figure 8. Screenshot 2 illustrating the exchange of referral letters between the HIS and the EHR
See this image and copyright information in PMC

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