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[放射治疗中的多模态文档管理]

[Multimodal document management in radiotherapy].

作者信息

Fahrner H, Kirrmann S, Röhner F, Schmucker M, Hall M, Heinemann F

机构信息

Klinik für Strahlenheilkunde, Radiologische Klinik, Universitätsklinikum Freiburg, Robert Koch Str. 3, 79106, Freiburg, Deutschland.

出版信息

Strahlenther Onkol. 2013 Dec;189(12):1032-9. doi: 10.1007/s00066-013-0451-x. Epub 2013 Nov 8.

Abstract

BACKGROUND AND PURPOSE

After incorporating treatment planning and the organisational model of treatment planning in the operating schedule system (BAS, "Betriebsablaufsystem"), complete document qualities were embedded in the digital environment. The aim of this project was to integrate all documents independent of their source (paper-bound or digital) and to make content from the BAS available in a structured manner. As many workflow steps as possible should be automated, e.g. assigning a document to a patient in the BAS. Additionally it must be guaranteed that at all times it could be traced who, when, how and from which source documents were imported into the departmental system. Furthermore work procedures should be changed that the documentation conducted either directly in the departmental system or from external systems can be incorporated digitally and paper document can be completely avoided (e.g. documents such as treatment certificate, treatment plans or documentation). It was a further aim, if possible, to automate the removal of paper documents from the departmental work flow, or even to make such paper documents superfluous. In this way patient letters for follow-up appointments should automatically generated from the BAS. Similarly patient record extracts in the form of PDF files should be enabled, e.g. for controlling purposes.

METHOD

The available document qualities were analysed in detail by a multidisciplinary working group (BAS-AG) and after this examination and assessment of the possibility of modelling in our departmental workflow (BAS) they were transcribed into a flow diagram. The gathered specifications were implemented in a test environment by the clinical and administrative IT group of the department of radiation oncology and subsequent to a detailed analysis introduced into clinical routine.

RESULTS

The department has succeeded under the conditions of the aforementioned criteria to embed all relevant documents in the departmental workflow via continuous processes. Since the completion of the concepts and the implementation in our test environment 15,000 documents were introduced into the departmental workflow following routine approval. Furthermore approximately 5000 appointment letters for patient aftercare per year were automatically generated by the BAS. In addition patient record extracts in the form of PDF files for the medical services of the healthcare insurer can be generated.

摘要

背景与目的

将治疗计划及治疗计划的组织模型纳入手术日程系统(BAS,即“betriebsablaufsystem”)后,完整的文档质量被嵌入数字环境。本项目的目标是整合所有文档,无论其来源是纸质还是数字,并以结构化方式提供BAS中的内容。应尽可能自动化许多工作流程步骤,例如在BAS中将文档分配给患者。此外,必须确保随时能够追踪是谁、何时、如何以及从哪些来源将文档导入部门系统。此外,应改变工作程序,以便直接在部门系统中或从外部系统进行的文档记录能够以数字方式整合,并完全避免纸质文档(例如治疗证书、治疗计划或文档记录等文档)。如果可能,进一步的目标是自动从部门工作流程中移除纸质文档,甚至使此类纸质文档变得多余。通过这种方式,应从BAS自动生成随访预约的患者信件。同样,应以PDF文件形式生成患者记录摘要,例如用于控制目的。

方法

一个多学科工作组(BAS-AG)详细分析了可用的文档质量,在对其在我们部门工作流程(BAS)中进行建模的可能性进行检查和评估后,将其转化为流程图。收集到的规范由放射肿瘤学系的临床和行政IT小组在测试环境中实施,并在详细分析后引入临床常规。

结果

该部门已成功在上述标准条件下,通过连续流程将所有相关文档嵌入部门工作流程。自概念完成并在我们的测试环境中实施以来,经常规批准后,15000份文档被引入部门工作流程。此外,BAS每年自动生成约5000封患者后续护理的预约信件。此外,还可以生成以PDF文件形式的患者记录摘要,供医疗保险公司的医疗服务使用。

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