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Almost 16 million Germans are treated annually in an emergency room (ER). Most patients are seen in a specialty ER and only 10-20% of all hospitals have a centralized ER facility. Clinical emergency medicine is currently not adequately reimbursed, but represents a major patient entry point for most hospitals. It remains unclear whether the implementation of specialized ER physicians is more cost-effective than centralized specialization. However, it appears reasonable to centralize all ER resources, to optimize the workflow using electronic patient charts and order entry sets and to incorporate the general practitioner into the treatment of simple medical problems.

The insertion of all patient details in one clinical information system (CIS) provides an enormous potential to rationalize and accelerate the administrative procedures in primary patient care. A successful data management system has to record not only the entire spectrum of the patient's medical data, but also the patient's personal data like name, address, date of birth, as well as names and addresses of other involved physicians. In addition, all aspects of the database gathered from varying sources must be compatible. The program has to be user-friendly enough that many different workers with varying backgrounds can effectively employ it. We investigated the effective saving of time in preparing a patient's discharge report based on conventional dictation using the clinical information system (Soarian) compared to a conventional, isolated word-processing program (Word). Existing potentials and limitations concerning the use of the CIS are presented. The objective analysis of measured processing times demonstrated a reduction for the typist, but no benefit for the physician dictating the discharge report. In the subjective perception of all users, the processing time appeared to have increased due to awkward editing and navigation functions. Improvements are required to increase the acceptance of the program by the users.

This paper examines a new approach to managed healthcare where a network of care providers exchanges patient information through the internet. Integrating networks of clinical specialists and general care providers promises to achieve qualitative and economic improvements in the German healthcare system. In practice, problems related to patient management and data exchange between the managing clinic and assorted caregivers arise. The implementation and use of a cross-spectrum computerized solution for the management of patients and their care is the key for a successful managed healthcare system. This paper documents the managed healthcare of chronic headache patients and the development of an IT-solution capable of providing distributed patient care and case management.

In Germany the documentation of processes in long-term care is mainly paper-based. Planning, realization and evaluation are not supported in an optimal way. In a preliminary study we evaluated the consequences of the introduction of a computer-based documentation system using handheld devices. We interviewed 16 persons before and after introducing the computer-based documentation and assessed costs for the documentation process and administration. The results show that reducing costs is likely. The job satisfaction of the personnel increased, more time could be spent for caring for the residents. We suggest further research to reach conclusive results.

Configuration of the interdisciplinary emergency unit within the university clinic of Göttingen was successfully reorganized during the past two years. All emergencies except traumatologic, gynecologic and pediatric emergencies are treated within this functional unit which is guided by the center of internal medicine. It is organized in a three shift operation manner over a period of 24 hours. Due to a close interdisciplinary collaboration between different departments patients receive optimal diagnostic and therapeutic treatment within a short period of time. To improve processes within the emergency department a series of measures were taken including the -establishment of an intermediate care unit for unstable patients, setting up of special diagnostic and therapeutic units for the acute coronary syndrome as well as stroke, implementation of standardized clinical pathways, establishment of an electronic data processing network in close communication with all diagnostic entities, introduction of a quality assurance system and reduction of medical costs. Reorganization measures lead to a substantial optimization and acceleration of emergency proceedings and thus, provides optimal patient care around the clock. In addition, medical costs could clearly be reduced at the interface between preclinical and clinical emergency medicine.

Background: Economic factors dominate more and more the healthcare systems; modern technologies advance every day and offer opportunities for savings., Material and Methods: In a pilot study, digital speech recognition based on Dragon NaturallySpeaking, Version 7 was compared with common dictation in dermatology., Results: The conventional method took 24.1 minutes per page and reports could be sent out after 16.8 days; in sharp contrast, the reports dictated by digital speech recognition took 15.8 minutes per page and were sent out after 3.2 days., Conclusion: Digital Speech recognition in dermatology has advantages compared to ordinary dictation, if the dictating person is trained with the software and it is implemented in a digital patient documentation system.

The economic aspects of the health telematics must be considered from two points of view. The administrative applications are suitable as start-applications, because their data structures and processes are well known, and the calculation of the individual monetary effects have a solid empirical basis. However, only the medical applications will exhaust the real potential of health telematics and only these applications will justify the political and financial effort involved.

Introduction: In times of easy world wide information transfer and reduced economic resources of the community, the presentation of medical departments in the internet becomes more and more important. But realisation is often insufficient., Method: The welcome page is the most important element. It should be appealing and easy to understand. Menues should lead to further information like "employees", "premises", "approach" and "medical information". Quick loading times are neccesary to make surfing more comfortable., Discussion: The internet presentation becomes more and more essential in our days. Legal restrictions, although being reduced in the last years, have to be observed.

Usually, hospitals and private doctors are well equipped with computers. However, the documentation of ultrasound data is commonly paper-based. The paper presents a computer-based ultrasound data recording and reporting, using the ultrasound documentation software Digisono.

German hospitals and surgical clinics/departments are facing far-reaching changes. One triggering factor is the imminent reorganization of hospital financing to a system of compensation, which is universally based on diagnosis-related groups (DRGs) and entails a market-economy orientation in the hospital sector. Digital technologies, which facilitate making the necessary adjustments to clinic structures to meet forthcoming challenges, represent another element. The "digital transformation" of the hospital of the future takes place on three levels. The restructuring of the surgical realm runs rather a traditional course by increasing use of information technology, mostly to optimize documentation and existing procedures or to reduce costs. The second sphere reaches substantially further, encompassing reorganization of disease-oriented cooperation between the different medical specialties and enabling the establishment of suitably structured disease-oriented medical centers. This is followed by the third phase, which involves networking clinics or medical centers with private practitioners, aftercare and rehabilitation services, and other disease-oriented care providers.

Background: The aim of this study is to compare the costs and benefits of electronic, paperless patient records with the conventional paper-based charts., Methods: Costs and benefits of planned electronic patient records are calculated for a University eye hospital with 140 beds. Benefit is determined by direct costs saved by electronic records., Results: In the example shown, the additional benefits of electronic patient records, as far as they can be quantified total 192,000 DM per year. The costs of the necessary investments are 234,000 DM per year when using a linear depreciation over 4 years. In total, there are additional annual costs for electronic patient records of 42,000 DM. Different scenarios were analyzed. By increasing the time of depreciation to 6 years, the cost deficit reduces to only approximately 9,000 DM. Increased wages reduce the deficit further while the deficit increases with a loss of functions of the electronic patient record. However, several benefits of electronic records regarding research, teaching, quality control and better data access cannot be easily quantified and would greatly increase the benefit to cost ratio., Conclusion: Only part of the advantages of electronic patient records can easily be quantified in terms of directly saved costs. The small cost deficit calculated in this example is overcompensated by several benefits, which can only be enumerated qualitatively due to problems in quantification.

Possibilities of an EDP-based quality management for medical networks are presented and some organizational requirements are derived. To show the relevance of the approach, three networks are sketched.

The introduction of electronic anaesthesia documentation systems was attempted as early as in 1979, although their efficient application has become reality only in the past few years. The advantages of the electronic protocol are apparent: Continuous high quality documentation, comparability of data due to the availability of a data bank, reduction in the workload of the anaesthetist and availability of additional data. Disadvantages of the electronic protocol have also been discussed in the literature. By going through the process of entering data on the course of the anaesthetic procedure on the protocol sheet, the information is mentally absorbed and evaluated by the anaesthetist. This information may, however, be lost when the data are recorded fully automatically-without active involvement on the part of the anaesthetist. Recent publications state that by using intelligent alarms and/or integrated displays manual record keeping is no longer necessary for anaesthesia vigilance. The technical design of automated anaesthesia records depends on an integration of network technology into the hospital. It will be appropriate to connect the systems to the internet, but safety requirements have to be followed strictly. Concerning the database, client server architecture as well as language standards like SQL should be used. Object oriented databases will be available in the near future. Another future goal of automated anaesthesia record systems will be using knowledge based technologies within these systems. Drug interactions, disease related anaesthetic techniques and other information sources can be integrated. At this time, almost none of the commercially available systems has matured to a point where their purchase can be recommended without reservation. There is still a lack of standards for the subsequent exchange of data and a solution to a number of ergonomic problems still remains to be found. Nevertheless, electronic anaesthesia protocols will be required in the near future. The advantages of accurate documentation and quality control in the presence of careful planning outweight cost considerations by far.

By means of complete service control and standardized accounting processes, radiological information systems clearly contribute to improved results. They provide the prerequisites for the establishment of expanded networks and allow comparisons with comparable institutions. The quality of patient care can be improved since, for example, the production time from referral to finished result becomes shorter. Direct access to patient and findings data from several positions is possible. Preliminary results can be viewed immediately. The patient's history is accessible to authorized users at all times. The exact reproducibility and assignment of services leads to more clarity. By means of the information available form RIS, rapid adaptive processes can be undertaken. The system assists the to fulfill the requirements of health regulations. The above-mentioned relationships demonstrate that the EDP systems are well accepted by physicians, medical assistants, and administrators and represent an indispensable aid for solving problems.

Objectives: A comparison of data from different intensive care units (ICUs) needs standardized documentation. In this study the ASDI documentation standard for intensive care was tested in clinical practice. Goal of the study was to evaluate parameters and functionality required for a national, interdisciplinary documentation system for intensive care., Design: 13 ICUs participated in a 4-week trial using the provided program for documentation of all admitted patients during the observation period. In addition, a questionnaire was distributed to the unit coordinators., Results: 376 patients were documented in 1591 patient days. Valid SAPS II scores were found in only 29% of the discharged patients (39.1 +/- 15.5 points). Time needed for data entry exceeded preset limits (ten minutes per patient and day) in 38% of the cases. All participants affirmed the necessity of a documentation standard for intensive care, giving quality control and cost analysis as the most important reasons., Conclusion: The ASDI data set fitted existing needs very closely. Only 7 out of 122 parameters (5.7%) were found to be superfluous and thus removed. Measures to reduce documentation effort to the default limits were a) a new, date orientated concept for manual recording, b) rede-sign of the user interface with new, user friendly data entry possibilities, and c) the integration of statistical analysis and reports in the documentation system. The revised data set represents a broad-based consensus, which seems to be well-suited as foundation for the national quality assurance program.

Information technology and networks should improve health care in the next few years. But the information systems in use are open systems; processing and transporting data by them is incompatible with the high privacy requirements of patient information. We have the technical means to achieve better security, but we cannot build them into existing systems by way of addition--the suppliers of hard- and software must integrate them into the systems, beginning with the system design, in a way that doesn't detract users from their proper tasks; users shouldn't have to do more than log into the IT system with their Health Professional Card. On the other hand the expense of organisational means and security personnel in health care environment is not negligible. But a thorough realization of security features will substantially improve the quality of information and the compliance with the law. The costs will reduce the profit of information technology, but not completely.

In Intensive Care Units (I.C.U.), the lack of staff and funds require the mobilisation of organisational reserves in order to ensure high-quality patient care. Traditional occupational-group organised documentation systems are burdened with lack of clarity, limited utilisation by the staff, insufficient information content and difficulties in synoptic patient monitoring. They cannot meet the demands of modern intensive-care medicine. At the inauguration of our Surgical I.C.U. in June 1992, an occupational-group oriented documentation system was introduced and put into operation. Because of negative repercussions on patient care, it was replaced by a patient-centered, conventional prescription and documentation system in April 1993. In April 1994, an evaluation of the patient-centered system was carried out. We report on our initial problem analysis, the subsequent developmental and introductory phases, and the results after having used the system in our I.C.U. for one year. Data condensation, standardised data recording, as well as structured prescription, examination, assessment and decision processes, saved 730 working hours for medical and nursing staff per year, reduced the cost for documentation materials by 58% and improved the extent of data recording. In our experience, improving a conventional documentation system is a suitable instrument to support cost reduction and preventive internal quality management in the I.C.U.

Documentation is becoming an ever more time-consuming task due to the need to document increasing ICU productivity, quality management and cost-assessment data. Automatic charting of on-line monitoring data, therapeutic-device data, clinical laboratory data, microbiological data, radiological data and other data reduces documentation time significantly. One of the major advantages of PDMS in the SICU is the quality of the documentation and with better documentation the therapist is able to improve the quality of care. Not only the physician, but also nurses and physiotherapists are able to benefit from these advantages. Our concept, SURGIC (Department of Surgery, University Regensburg, Germany, Intensive Care), stands for: widely automated documentation, work orientation, including physicians, nurses' and physiotherapists' tasks, minimal dataset for simple use and perfect overview, costs assessments, scientific dataset, SICU PDMS as a part of the clinical information system, and professional support by a software-house is necessary.