Division IT, Charité - Universitätsmedizin Berlin;
Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin.
J Vis Exp. 2021 Apr 13(170). doi: 10.3791/61971.
TBase is an electronic health record (EHR) for kidney transplant recipients (KTR) combining automated data entry of key clinical data (e.g., laboratory values, medical reports, radiology and pathology data) via standardized interfaces with manual data entry during routine treatment (e.g., clinical notes, medication list, and transplantation data). By this means, a comprehensive database for KTR is created with benefits for routine clinical care and research. It enables both easy everyday clinical use and quick access for research questions with highest data quality. This is achieved by the concept of data validation in clinical routine in which clinical users and patients have to rely on correct data for treatment and medication plans and thereby validate and correct the clinical data in their daily practice. This EHR is tailored for the needs of transplant outpatient care and proved its clinical utility for more than 20 years at Charité - Universitätsmedizin Berlin. It facilitates efficient routine work with well-structured, comprehensive long-term data and allows their easy use for clinical research. To this point, its functionality covers automated transmission of routine data via standardized interfaces from different hospital information systems, availability of transplant-specific data, a medication list with an integrated check for drug-drug interactions, and semi-automated generation of medical reports among others. Key elements of the latest reengineering are a robust privacy-by-design concept, modularity, and hence portability into other clinical contexts as well as usability and platform independence enabled by HTML5 (Hypertext Markup Language) based responsive web design. This allows fast and easy scalability into other disease areas and other university hospitals. The comprehensive long-term datasets are the basis for the investigation of Machine Learning algorithms, and the modular structure allows to rapidly implement these into clinical care. Patient reported data and telemedicine services are integrated into TBase in order to meet future needs of the patients. These novel features aim to improve clinical care as well as to create new research options and therapeutic interventions.
TBase 是一款电子健康记录 (EHR) 系统，适用于肾移植受者 (KTR)，它通过标准化接口自动输入关键临床数据（例如实验室值、医学报告、放射学和病理学数据），并在常规治疗期间手动输入数据（例如临床记录、药物清单和移植数据）。通过这种方式，为 KTR 创建了一个全面的数据库，为常规临床护理和研究带来了好处。它既便于日常临床使用，又便于研究人员快速获取高质量的数据来解决研究问题。这是通过在临床常规中数据验证的概念实现的，在这种概念下，临床医生和患者必须依靠正确的数据来制定治疗和药物计划，从而在日常实践中验证和纠正临床数据。这个 EHR 是为移植门诊护理的需求而定制的，在柏林夏里特医科大学已经使用了 20 多年，证明了其在临床实践中的实用性。它通过结构化、全面的长期数据来提高日常工作效率，并方便临床研究人员使用这些数据。其功能包括通过标准化接口从不同的医院信息系统自动传输常规数据、提供移植专用数据、具有药物相互作用检查功能的药物清单以及半自动生成医疗报告等。最新重构的关键要素包括稳健的隐私设计理念、模块化以及由此带来的可移植性，能够在其他临床环境中使用，还具有 HTML5（超文本标记语言）支持的响应式网页设计带来的易用性和平台独立性。这使得它能够快速、轻松地扩展到其他疾病领域和其他大学医院。全面的长期数据集是机器学习算法研究的基础，模块化结构允许快速将这些算法应用于临床护理。患者报告数据和远程医疗服务也集成到 TBase 中，以满足患者的未来需求。这些新功能旨在改善临床护理，同时为创建新的研究选项和治疗干预措施提供支持。
