Dick B, Basad E
Universitäts-Augenklinik Giessen.
Klin Monbl Augenheilkd. 1996 Apr;208(4):254-61. doi: 10.1055/s-2008-1035207.
As a result of new health care guidelines (Gesundheitsstrukturgesetz) and the federal hospital and nursing ordinance, there has been a large increase in the documentation required for diagnoses (ICD-9) and service ("Operationenschlüssel nach section 301 SGB V" = ICPM), all of which is done in the form of a numeric code. The method of coding diagnoses is supposed to make possible data entry and statistical evaluation of plausibility controls, as well as conspicuous and random testing of economic feasibility. Our data processing system is designed to assist in the planning and organization of clinical activities, while at the same time making documentation in accordance with health care guidelines easier and providing scientific documentation and evaluation.
The application MedAccess was developed by clinicians on the basis of a relational client-server database. The application has been in use since June 1992 and has been further developed during operation according to the requirements and wishes of clinic and administrative staff. In cooperation with the Institute for Medical Information Technology, a computer interface with the patient check-in system was created, making possible the importing of patient data. The application is continuously updated according to the current needs of the clinic and administration. The primary functions of MedAccess include managing patient data, planning of in-patient admissions, surgical planning, organization, documentation (surgery book, reports with follow-up treatment records), administration of the tissue bank, clinic communications, clinic work processing, and management of the staff duty roster.
Clinical data are entered into a computer and processed on site, and the user is assisted by practical applications which do not require special knowledge of data processing or encoding systems. The data is entered only once, but can be further used for other purposes, such as evaluations or selective transfer, for example, to clinical documents. Through an integrated flow of data, information entered one time remains readily available, while, at the same time, preventing duplicate entries. The integration of hardware and software via a mainframe computer (clinic system WING) has proven to be well-suited for the exchange of data.
The use of this thesaurus-supported and graphics-oriented system required no special knowledge of the ICD code and makes documentation much easier to produce. The advantages of computer-supported encoding not only include a savings in time, but also an improvement in the quality of the encoding from which clinical and scientific reports can be derived. The relational client-server, operating in a graphics-supported programming environment, makes it possible for the clinic's doctors to further develop and improve the system. Through the installation and support of a Macintosh network, and training of doctors, medical personnel and clerical staff, cost as well as investment of time have been kept to a minimum in comparison to other LAN servers.
由于新的医疗保健指南（《健康结构法》）以及联邦医院和护理条例，诊断（ICD - 9）和服务（“《社会法典第五编》第301条的手术编码” = ICPM）所需的文档记录大幅增加，所有这些均以数字代码形式完成。诊断编码方法旨在实现数据录入以及对合理性控制进行统计评估，同时对经济可行性进行显著和随机测试。我们的数据处理系统旨在协助临床活动的规划和组织，同时使符合医疗保健指南的文档记录更加简便，并提供科学文档记录和评估。
应用程序MedAccess由临床医生基于关系型客户端 - 服务器数据库开发而成。该应用程序自1992年6月起投入使用，并在运行过程中根据临床和行政人员的要求及愿望进一步开发。与医学信息技术研究所合作，创建了与患者登记系统的计算机接口，从而能够导入患者数据。该应用程序会根据诊所和行政部门的当前需求持续更新。MedAccess的主要功能包括管理患者数据、规划住院治疗、手术规划、组织安排、文档记录（手术记录册、带有后续治疗记录的报告）、组织库管理、诊所通信、诊所工作流程处理以及员工值班表管理。
临床数据在现场输入计算机并进行处理，实用的应用程序为用户提供协助，这些应用程序无需数据处理或编码系统的专业知识。数据仅需输入一次，但可进一步用于其他目的，例如评估或选择性传输，例如传输至临床文档。通过集成的数据流，一次输入的信息随时可用，同时防止重复录入。通过大型计算机（诊所系统WING）实现硬件和软件的集成，已证明非常适合数据交换。
使用这个由词库支持且面向图形的系统无需对ICD代码有专业知识，并且使文档记录的生成更加容易。计算机辅助编码的优势不仅包括节省时间，还包括提高编码质量，从而能够生成临床和科学报告。在图形支持的编程环境中运行的关系型客户端 - 服务器，使诊所的医生能够进一步开发和改进该系统。通过安装和支持Macintosh网络以及培训医生、医务人员和文书工作人员与其他局域网服务器相比，成本以及时间投入已降至最低。
