Meta-Medical-Record in Telemedicine

A lot of health care professionals are involved in the treatment of a patient. This will even increase, if telemedicine applications are used. All treating physicians are collecting data so that finally there exists a lot of redundant paper based information in various formats and at various locations. Unfortunately, there are numerous heterogeneous information systems in use, which are not compatible with each other. This makes an automated data exchange almost impossible [Bethke, 1998, p. 105]. Facing the situation that several physicians are

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involved in a patient’s treatment process or that nowadays ‘mobility’ of people increases permanently (holidays, flexible labor market), it would be from high value for physicians if they were able to review the medical record with all previous data and treatment descrip-tions of a patient [Sandberg, 1995]. Today a single physician has only access to his self-collected patient data. Not rarely he/she spends a lot of time gathering information by re-viewing voluminous paper charts and tracking down patient information on the phone or in various parts of the hospital or at other locations [Steiniger, 1994]. This is no surprise, since the term computer-based patient record is still used in the narrow sense of automating today's paper records and the vision for future clinical computing seems to be limited to clinical data repositories [Amatayakul, 1995].

The effect of such paper storage is that a lot of space and time for sorting, archiving, and retrieval of data is needed. The documents are often in different formats, unreadable, re-dundant, incomplete or disappear at all [Löbus, 1997/(2), pp. 13-14; Detken, 1996, p. 101].

A fair amount of time is further required for patient records to be dictated, transcribed, and sent to referring physicians [Williams, 1995]. This situation frustrates physicians and make the treatment of the patient and the health care delivery system inefficient. To allow an instant access to any health data about an individual, several institutions and projects have to be active in developing computer-based patient record.

Projects for the Design of Medical Records

One project is designed by the Pacific Bell Health Care Market Group, which is expected to be used by half of California's health care providers. As a backbone, a virtual computer-based patient record system will be implemented. Once the whole system is ready to use, physicians are able to take advantage of clinical messaging applications, they can transmit and receive orders and results, and eventually discharge patients [Braly, 1995/(2)].

Another project started in June 1994, when Europe's first independent academic medical center, the Health Care International Medical Center (HCI) in Clydebank, Scotland, started its work. As an approach to health care for the international community, the key-objective of this medical center is, to make high-tech, specialized care more accessible and afford-able, regardless of resources available at the patient's locale. The goal of world-wide medi-cal consulting is, to convey patient information to specialists for consultations, treatments and follow-up care without the restriction of time and space. The core of the service is the electronic creation, transmission, amendment, storage and retrieval of patient information in a central electronically database. The data of these medical records is collected at all points within the health care system. This way information from various departments and points of patient contact can be integrated, which leads to an almost paperless environ-ment²³. Patient's information like electronic images, assessments, documentation, medica-tions, tests and procedures, etc., is up-to-the-minute available in admissions, at the bedside, in ancillary departments, operating theatres, in physician offices and even at physician’s homes [Mariner, 1995].

The Los Alamos National Laboratory works on a concept for virtual patient records, which are available through references (analogous to hypertext links of the World Wide Web) and are only brought together on demand by the end user. The idea behind that is that physi-cians generally access components of a record rather than the entire patient record

23 The only paper documents stored are released forms signed by patients.

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[Forslund, 1996]. Further, employing multimedia features, the University of Pittsburgh has embarked on a venture called the Image Engine Project, which has the objective of per-fecting a multimedia electronically medical record [O’Brien, 1998, p. 154].

In Germany, the ’BERMED’ project between the heart center of Berlin, the Rudolf Vir-chow University Berlin, and several other hospitals and physicians around Berlin is pursu-ing the aim to integrate distributed patient data in a object-orientated multimedial elec-tronically medical record database constructed on the client server principles. But it is dif-ficult to overcome the problem of different document qualities and formats. An integrated medical application with a well designed graphical user interface helps the physician to easily access patient data, to carry out data retrieval, to generate diagnostic results, to ma-nipulate digital images or to support desktop conferencing [Deutsch, 1996, p. 793]. An-other approach is designed by the DLR (Deutsches Zentrum für Luft- und Raumfahrt, In-stitut für Luft- und Raumfahrtmedizin) in Cologne, Germany. The DLR discovers how to tie already existing date sources to an electronic medical record for telemedical services [Dethke, 1998].

A good survey about institutions in the USA, which consider the questions of medical re-cord standards, are listed by Houtchens [Houtchens, 1995, p. 98] and Detmer [Detmer, 1994] and will be examined more detailed in chapter fourteen (14.2.1). I just want to name some of the most important standard setting bodies: The American College of Physicians, the Institute of Medicine, the American Hospital Association, the Computer-Based Patient Record Institute, or the federal government's Work Group on Computerization of Patient Records.

It is obvious that the developments in the standardization of medical records affect tele-medicine, since physicians or other legitimate users all over the world are involved in the procedures of telemedicine and they all need the data of the patient to give up a qualified statement. Of course, questions about data protection and security, legal restrictions, ten-ability of storage media, etc., have to be answered before such a system can be used on a regular basis. On a long term basis, electronic medical record systems should become an essential part of the integrated health care delivery system and provide valuable informa-tion for statistics and medical research, for clinical decision-support systems as well as for other medical knowledge bases. By this way an almost paperless, more patient-centered and clinical process orientated computing environment will be created.

Smart Cards

As long as easy accessible integrated medical records are not available, so called ‘smart cards’ or ‘patient chip cards’ were developed. Such cards contain for example administra-tive patient data (cardholder identity, insurance information, private insurance data and person to call in emergency), patient medical data (history, specialist doctor’s names, stay in hospital, data about examinations), biological data (blood analysis, blood group, and agglutination), as well as pharmacy data (current treatment, prescription, and delivery) [Güler, 1998, p. 407; Lischka, 1996²⁴].

24 More information see: http://www.kp.klr.de; „Telemedizin - Stand und Ausblick“

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