Fuhrmann L, Böhringer D, Gass P, Dicke C, Eter N, Schargus M
Asklepios Augenklinik Nord-Heidberg, Tangstedter Landstraße 400, 22417, Hamburg, Deutschland.
Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Freiburg, Deutschland.
Ophthalmologie. 2022 Aug;119(8):827-833. doi: 10.1007/s00347-022-01605-7. Epub 2022 Apr 4.
Electronic medical records are required in ophthalmology clinics to be integrated into digital care networks and efficient clinical registry databases.
To assess the prevalence and methods of electronic medical recordkeeping in inpatient ophthalmological care in Germany.
An online questionnaire was sent to all German university eye hospitals and ophthalmology departments in June 2021. It included 13 open and closed option questions concerning current practices of digital recordkeeping, including the structure of data storage and the recording of billing-relevant codes in the departments.
A total of 44 (44%) out of 100 clinics responded. Patient documentation was completely digital in 15 (34%) clinics and partly digital and paper-based in the remaining 29 (66%). A total of 16 different constellations of documentation programs were specified. The most frequently used programs were Orbis (27%) (Dedalus HealthCare, Bonn, Germany), FIDUS (18%) (Arztservice Wente, Darmstadt, Germany), and SAP/i.s.h.med (16%) (SAP Deutschland, Walldorf, Germany; Cerner Deutschland, Berlin, Germany) and 3 clinics indicated primary use of paper records. Structured documentation of findings was performed in 61% of the departments, while 23% used a semistructured manner and 15% used a nonstructured format. Electronic documents are stored as DICOM (Digital Imaging and Communications in Medicine) documents 20% of the clinics and as PDF (Portable Document Format) files in 34% of the clinics while 23% store scanned printouts.
Methods of medical record keeping in German eye clinics are heterogeneous, with paper-based documentation continuing to play an important role. This, as well as the high number of different electronic medical record software pose important challenges in terms of interoperability and secondary use of clinical data.
眼科诊所需要电子病历，以便集成到数字护理网络和高效的临床登记数据库中。
评估德国住院眼科护理中电子病历保存的普及率和方法。
2021年6月，向德国所有大学眼科医院和眼科科室发送了一份在线问卷。问卷包含13个关于数字记录保存现行做法的开放式和封闭式选择题，包括数据存储结构和科室中与计费相关代码的记录。
100家诊所中共有44家（44%）做出回应。15家（34%）诊所的患者文档完全数字化，其余29家（66%）部分数字化且有纸质文档。共指定了16种不同的文档程序组合。最常用的程序是奥比斯（27%）（德国波恩的德达勒斯医疗保健公司）、菲杜斯（18%）（德国达姆施塔特的温特医疗服务公司）和SAP/i.s.h.med（16%）（德国瓦尔道尔夫的SAP德国公司；德国柏林的erner德国公司），3家诊所表示主要使用纸质记录。61%的科室对检查结果进行结构化记录，23%采用半结构化方式，15%采用非结构化格式。20%的诊所将电子文档存储为DICOM（医学数字成像和通信）文档，34%的诊所存储为PDF（便携式文档格式）文件，23%的诊所存储扫描打印件。
德国眼科诊所的病历保存方法多种多样，纸质文档仍发挥着重要作用。这以及大量不同的电子病历软件在临床数据的互操作性和二次使用方面带来了重大挑战。
