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Background: In 2004, Germany introduced a nationwide DRG (Diagnosis Related Groups) based recompensation system for hospitals. The aim of this study was to provide nationwide quantitative information about the in-hospital management of skin cancer patients in Germany based on the DRG statistic of the years 2005 through 2006., Methods: We analysed the DRG statistic of the years 2005 and 2006. For each hospitalisation, diagnoses and procedures codes were analysed. The unit of analysis was the hospital admission with a diagnosis of skin melanoma (MEL) or nonmelanoma skin cancer (NMSC) including 151.144 hospitalisations., Results: In 60% and 28% of all MEL- and NMSC-related hospitalisations respectively, skin cancers were surgically excised. Local therapies other than surgical excision were more prevalent among hospitalisations for NMSC than for MEL (9% vs. 4%). 22% and 1% of all MEL-related and NMSC-related hospitalisations respectively included a systemic chemotherapy. Plastic surgery was more common among NMSC-related hospitalisations (56%) than among MEL-related hospitalisations (30%). Native CT or MRI scans were coded in 11% and 2% of all MEL- and NMSC-related hospitalisations respectively. Age-standardized hospitalisation rates for MEL and NMSC varied considerably across the 16 Federal States of Germany. However, these rates were neither associated with the number of dermatology hospital beds or number of registered dermatologists., Discussion: We provide for the first time nationwide quantitative data on the in-hospital management of skin cancer patients. The observed differences in the management of MEL and NMSC most likely reflect differences of the biology, epidemiology and therapeutic modalities of these cancers.

Different classifications of pressure ulcer are in use making national and international studies on epidemiological issues as well as on effects of prophylactical and therapeutical interventions difficult. A systematic literature search identified 31 pressure ulcer classifications. Thirteen could be retrieved and were further analyzed. Six variants of the International Classification of Diseases (ICD) differ totally in number of classes, hierarchical structure, characteristics included, and level of detail. They share only the fact of a "pressure ulcer". Recommendations of expert organizations and clinical classifications differ as well. The currently introduced grade "suspected deep tissue injury" in the classification proposed by the US-National Pressure Ulcer Advisory Panel (NPUAP) is neither present in the European Pressure Ulcer Advisory Panel (EPUAP) one, nor in the ICD variants. Being aware of the reliability issue in pressure ulcer diagnosis and grading, the situation is appalling. Furthermore, stage adjusted quality assessment, prophylaxis and therapy ends with the borders of a classification. We call the WHO to initiate a harmonization of the ICD variants of pressure ulcer classification and to cooperate with experts' organizations in this field, particularly with regard to the development of ICD-11. Reports on pressure ulcer should always mention the classification used.

The planning of case report forms (CRFs) in clinical trials or databases in registers is mostly an informal process starting from scratch involving domain experts, biometricians, and documentation specialists. The Telematikplattform für Medizinische Forschungsnetze, an umbrella organization for medical research in Germany, aims at supporting and improving this process with a metadata repository, covering the variables and value lists used in databases of registers and trials. The use cases for the metadata repository range from a specification of case report forms to the harmonization of variable collections, variables, and value lists through a formal review. The warehouse used for the storage of the metadata should at least fulfill the definition of part 3 "Registry metamodel and basic attributes" of ISO/IEC 11179 Information technology - Metadata registries. An implementation of the metadata repository should offer an import and export of metadata in the Operational Data Model standard of the Clinical Data Interchange Standards Consortium. It will facilitate the creation of CRFs and data models, improve the quality of CRFs and data models, support the harmonization of variables and value lists, and support the mapping of metadata and data.

Objective: Using the National Statistics ('DRG-Statistik') published by the Federal Statistical Office, we analyzed prevalences of pressure ulcers coded as principal or as additional diagnosis separately and describe differences in ulcer characteristics., Patients and Methods: Age-adjusted prevalence and tables for gender and age distribution of pressure ulcers separately for the principal diagnosis and for additional diagnoses were provided by the Federal Statistical Office., Results: In 2005, about 16 million patients were treated as full-time patients in German hospitals. 9,941 (0.06%) were referred with pressure ulcer as principal diagnosis and 191,040 (1.19%) had at least one additional diagnosis pressure ulcer. People >65 years of age had the highest risk for pressure ulcers (per 100,000 population principal diagnosis: females 52 and males 37; additional diagnosis: females 1,076 and males 947). Up to 80% of those who had the principal diagnosis pressure ulcer had ulcers grade 3 and 4, whereas 60% of the pressure ulcers documented as additional diagnosis were grade 1 and 2 (p < 0.001). The most frequent localizations of pressure ulcers were the ischium, the sacrum and the heel. In patients <65 years of age with the principal diagnosis pressure ulcer, the mortality rate is <0.1%. In the older age groups it increases gradually up to 10% in the 8th decade of life., Conclusion: Pressure ulcers are still a relevant problem in Germany. Although patients 65 years and older are at the highest risk, all age groups are affected. Younger people seem to struggle with different problems compared to older people., (Copyright 2008 S. Karger AG, Basel.)

We undertook a systematic review of the literature on the basis of published studies on the benefit and costs of Electronic Patient Records (EPRs) to clarify the issue of whether and to what extent the use of an EPR is worthwhile. We carried out a systematic electronic search for articles published between 1966 and early 2004 using MEDLINE, following up cross-references from the articles found. We searched first for suitable medical subject headings (MeSH) for electronic patient record, benefit and costs. We obtained 7860 citations with the MeSH keyword ''Medical Record System, Computerized". After combination with appropriate keywords this number was reduced to 588, after a review by two reviewers independently based on abstracts down to 95, and after a further review based on full-text articles to 19 covering 20 studies. The publications evaluated thus document the economic benefits of EPR in a number of areas, but they do not make a statement of the cost effectiveness of EPR in general.

Background: The aim of the study was to check the validity of the electronic patient records for hospital-acquired pneumonia and to estimate their reliability., Patients and Methods: On reviewing 23,356 inpatients with admission from 1st April 2005 and discharge up to the 30th September 2005, we identified 211 cases with hospital-acquired pneumonia in the electronic patient records whereby 70 cases taken at random were included in the calculation of the positive predictive value. A second random sample of 130 cases under risk was used to calculate its sensitivity. Positive predictive value and sensitivity were combined to estimate the true rate of hospital-acquired pneumonia., Results: In 64.3 % of the cases hospital-acquired pneumonia was confirmed in the paper-based patient records (45 cases, 95 % confidence interval 51.9 - 75.4 %). Sensitivity was calculated as 42.9 % and specificity as 99.0 %. Estimation for the University Clinics Essen revealed a true rate of hospital-acquired pneumonia of 1.32 %. The estimated true rate was higher than the measured rate of 0.90 % which is covered, nevertheless, by the 95 % confidence interval., Conclusions: Results from electronic and paper-based patient records are similar for hospital-acquired pneumonia, in spite of relevant differences on the level of the individual cases. However, data quality is not sufficient for special claims of supervision, clinical hygiene and prevention, for which a further optimisation is required.

Introduction: Non-melanoma skin cancer (NMSC), in contrast to skin melanoma (MEL), is considered a negligible health problem because mortality of NMSC is low. The aim of this study was to provide insights into the burden of NMSC and MEL by analysing nationwide skin cancer hospitalization data and data from a dermatologist panel of Germany. We wanted to estimate hospitalization costs due to skin cancer in Germany., Material and Methods: We analysed the most recent nationwide hospitalization data from 2003 and estimated hospitalization costs due to MEL and NMSC. We estimated the annual number of private dermatologist practice visits in Germany due to skin cancer., Results: In 2003, 20 455 melanoma-related and 41 929 NMSC-related hospitalizations occurred in Germany. Age-standardized hospitalization rates for NMSC were 2.5-fold and 1.8-fold higher among men and women than the rates for MEL, respectively. The age-specific proportions of hospitalizations for NMSC in relation to all cancer-related hospitalizations increased within the age range of 65 years and more. Among people aged 90 years and more, 14% of all cancer-related hospitalizations were due to NMSC. Estimated annual hospitalization costs for MEL were euro50 to 60 million, and those for NMSC were euro105 to 130 million. The estimated number of private dermatologist practice visits in Germany 2003 is considerably higher for NMSC than MEL CONCLUSIONS: Analyses of hospitalizations data and data from private dermatologists give NMSC higher public health relevance than can be obtained from consideration of death statistics.

Aim of the study was to check the validity of the electronic patient record for hospital-acquired pneumonia and to estimate its reliability. Reviewing 23,356 inpatients with admission from the 1st April 2005 and discharge up to the 30th September 2005 we identified 211 cases with hospital-acquired pneumonia in the electronic patient record whereof 70 cases taken at random were included in the validation. A second random sample of 130 cases under risk was used to calculate its completeness. For hospital-acquired pneumonia, the latest version of the definition of the Centers for Disease Control and Prevention (CDC) was applied. In 64.3% of the cases hospital-acquired pneumonia was confirmed in the paper-based patient record (45 cases, 95%-confidence interval 51.9%-75.4%). Beside 10 cases with pneumonia already existing with admission 15 cases remain where even pneumonia could not be confirmed in the paper-based patient record. Completeness was calculated as 42.9%. Estimation for the University Clinics Essen revealed a true rate of hospital-acquired pneumonia of 1.32% (308 of 23,356). The estimated true rate was higher than the measured rate of 0.90% (211 of 23,356) which is covered, nevertheless, from the 95%-confidence interval. Data from the electronic patient record seem to be sufficient to forecast the true rate of hospital-acquired pneumonia, for example, for questions of infectious disease epidemiology. However, it is not sufficient enough for special claims of the supervision, clinical hygiene and prevention for which an optimization of the data quality is required.

Background: The reliability and validity of pressure ulcer diagnosis and grading are major methodological issues in studies and reports on pressure ulcer frequency., Objectives: The aim of the study was to estimate the reliability and validity of pressure ulcer diagnosis and grading within the interdisciplinary pressure ulcer project of the University Clinics of Essen, Germany., Design: Fifty images of wounds from the foot/heel region and 50 images of wounds from the buttock/hip region were classified using a 4-grade scale. A gold standard was established by consensus of two senior physicians., Settings: The images were assessed PC-based, independently by each rater., Participants: Five nursing experts and two physicians participated., Methods: Mean simple Kappa and per cent agreement were calculated to assess reliability and validity., Results: Mean simple Kappa values showed a moderate interrater agreement for grading and a fair interrater agreement for diagnosis. The percentage of agreements was highest for pressure ulcer diagnosis in the buttock/hip region with 90.5% and lowest for pressure ulcer grading in the buttock/hip region with 63.5%. No differences could be found between nurses and physicians., Conclusions: The differentiation between pressure ulcers and other skin lesions is rather difficult. It is important to assign the lower grade when the available information does not definitely support the higher grade. The level of agreement found was intermediate in the range of published results. A substantial level of agreement should be obtainable through further standardisation and training. Future studies should control for dependency in the assessment situation and dispense with the category "uncertain".

Routine data in the electronic patient record are frequently used for secondary purposes. Core elements of the electronic patient record are diagnoses and procedures, coded with the mandatory classifications. Despite the important role of routine data for reimbursement, quality management and health care statistics, there is currently no systematic analysis of coding quality in Germany. Respective concepts and investigations share the difficulty to decide what's right and what's wrong, being at the end of the long process of medical decision making. Therefore, a relevant amount of disagreement has to be accepted. In case of the principal diagnosis, this could be the fact in half of the patients. Plausibility of coding looks much better. After optimization time in hospitals, regular and complete coding can be expected. Whether coding matches reality, as a prerequisite for further use of the data in medicine and health politics, should be investigated in controlled trials in the future.

Background: Starting with clinically motivated projects, the national quality assurance program has established a legislative obligatory framework. Annual feedback of results is an important means of quality control., Material and Methods: The annual reports cover quality-related information with high granularity. A synopsis for corporate management is missing, however. Therefore, the results of the University Clinics in Greifswald, Germany, have been analyzed and aggregated to support hospital management., Results: Strengths were identified by the ranking of results within the state for each quality indicator, weaknesses by the comparison with national reference values. The assessment was aggregated per clinical discipline and per category (indication, process, and outcome)., Conclusion: A composition of quality indicators was claimed multiple times. A coherent concept is still missing. The method presented establishes a plausible summary of strengths and weaknesses of a hospital from the point of view of the national quality assurance program. Nevertheless, further adaptation of the program is needed to better assist corporate management.

An essential aspect for the utilization of medical data is their quality, thus a main feature of computer-based medical documentation systems should be to assist the user in complete and plausible data acquisition and maintenance. In this paper we define a grammar for modeling medical documentation systems to increase integrity and completeness of collected data, focusing attention on integrity constraints. An integrity constraint defines requirements that involved entities had to comply with. Furthermore it defines possibly implications in case of failure. The constraints presented in this paper are type constraint, length constraint, domain constraint, key constraint, quantity constraint, reference constraint, search constraint, result constraint, hierarchy constraint, and semantic constraint. Their grammar is declared using a schema in extensible markup language-format (XML-schema). The model introduced here can be used in computer-aided design and implementation of clinical documentation both minimizing effort and ensuring data quality, which was tested by an evaluation based on a specification of a registry for HIV-infected patients.

Patients and health insurances are increasingly interested in the quality of care provided by hospitals. Quality indicators are often used to evaluate the quality of inpatient treatment. Most of these evaluations require the collection of additional data. The patient safety indicators (PSI) introduced by the Agency for Healthcare Research and Quality (AHRQ) are precisely validated and exclusively depend on routine data. The original PSI definitions were transferable to the classifications of diagnosis, procedures and DRG used in Germany, and applied to routine data of 2.3 million cases from more than 200 hospitals. The comparison of the results to the US references reveals high concordance between the rates and demonstrates that PSI can be applied to detect critical incidents of patient care. For PSI-based hospital benchmarking further development of appropriate methods of risk adjustment is necessary.

Issues of information management, quality management, process management, and empirical research are often seen independently from each other. In the Essen interdisciplinary pressure ulcer project, they were integrated to establish a synergy between quality of care, economics and research. The electronic documentation of events and supplementary information was done with the hospital wide patient administration system. Feedback and automatically requests were used for quality improvement. Codes for reimbursement are generated from the clinical documentation. Research studies had been based on the routine documentation. Prerequisite was the cooperation of all relevant groups, nurses, physicians, informaticians, theoreticians and medical controller. In the future, it will be necessary to extend the approach to other relevant nursing problems and to replace the redundant documentation (paper-based as well as electronic) by an electronic health record.

Appropriate data quality is a crucial issue in the use of electronically available health data. As source data verification (SDV) and feedback are two standard procedures for measuring and improving data quality it would be worthwhile to adapt these procedures to a current level of quality in order to reduce costs in data management. This project aims to develop a guideline for the management of data quality with special emphasis on this adaptation against the backdrop of research networks in Germany, which operate registers and conduct epidemiological studies. The first step in guideline development was a thorough literature review. The literature offers many measurements as candidates for quality indicators, however, systematic assessments and concepts of SDV and feedback are missing. We assigned possible quality indicators to the levels plausibility, organization, and trueness. Each indicator must be operationally defined to allow automatical calculation. The SDV sample size calculation leads to lower numbers for sites providing data of good quality and larger numbers for sites with poor data quality. The guideline's implementation in a software tool combines two cycles, one for the adaptation of recommendations to a given study/register, the other for the improvement of data quality in a PDCA-like approach. The recommendations will address needs common to medical documentation in daily health care, clinical, epidemiological, and observational studies as well as in surveillance data bases and registers. Further work will have to supplement other aspects of data management.

Background and Objective: Pressure ulcer is a relevant issue for quality management and cost containment of hospitals. Cross-sectional studies are the typical design to estimate the frequency of pressure ulcers. The derived point prevalence rate is not as good for a case related reference value as the period prevalence rate. The interdisciplinary pressure ulcer project at the University Clinics in Essen combined a routine documentation with a cross-sectional survey, thus providing both measurements for the first time., Patients and Methods: The routine and computer-based collection of information about pressure ulcers started in March 2003, using the patient administration system medico//s from Siemens. Findings are presented from 49,904 admissions, starting on 91/03/2004, discharged by 31/03/2004. The mean age was 48.7 +/- 22.4 years; 51.2 % were males, 48.8 % females. Additionally, a decubitus team examined patients from randomly selected wards each work-day. The real period prevalence rate was calculated using the observed period prevalence rate, the sensitivity and the point prevalence rate., Results: In the routine documentation, 700 pressure ulcers had been recorded from 49,904 inpatient cases (period prevalence rate 1.4 %). The decubitus team did 5,415 examinations and 294 times detected at least one pressure ulcer (point prevalence rate 5.4 %). Estimated results in three different period prevalence rates: 3.0 % using sensitivity of the routine documentation, 3.7 % using sensitivity stratified for departments, and 2.3 % using the point prevalence rate for cases with short, medium, and long length of stay., Conclusions: The project presents for the first time reference values for pressure ulcer frequency in university clinics. A comparison with international rates is hindered by unpublished sensitivity values. In view of the higher point prevalence rate of 10 % present in the literature, a period prevalence rate of 5 % is a realistic reference value.

Background: Diagnosis related groups (DRGs) are a well-established provider payment system. Because of their imminent potential of cost reduction, they have been widely introduced. In addition to cost cutting, several social objectives - e.g., improving overall health care quality - feed into the DRG system., Objectives: The WHO compared different provider payment systems with regard to the following objectives: prevention of further health problems, providing services and solving health problems, and responsiveness to people's legitimate expectations. However, no study has been published which takes the impact of different cost accounting systems across the DRG systems into account., Methods: We compared the impact of different cost accounting methods within DRG-like systems by developing six criteria: integration of patients' health risk into pricing practice, incentives for quality improvement and innovation, availability of high class evidence based therapy, prohibition of economically founded exclusions, reduction of fragmentation incentives, and improvement of patient oriented treatment., Results: We set up a first overview of potential and actual impacts of the pricing practices within Yale-DRGs, AR-DRGs, G-DRGs, Swiss AP-DRGs adoption and Swiss MIPP. It could be demonstrated that DRGs are not only a 'homogenous' group of similar provider payment systems but quite different by fulfilling major health care objectives connected with the used cost accounting methods., Conclusions: If not only the possible cost reduction is used to put in a good word for DRG-based provider payment systems, maximum accurateness concerning the method of cost accounting should prevail when implementing a new DRG-based provider payment system.

Catalogues of medical E-learning modules offer easy access to learning material that is available on the World Wide Web (WWW) free of charge. Therefore, a study was conducted on the retrieval performance of four WWW-based catalogues: CAL reviews, KELDAmed, LMU, and LRSMed. LRSMed is run by the authors. Completeness was calculated pairwise. Two reviewers checked the availability of 80 modules independently. Five criteria were chosen to calculate accuracy: gynaecology and microbiology as medical fields; case study as type of learning resource; diabetes mellitus and AIDS as free-text diagnoses. Also, two reviewers evaluated independently whether the module is really an appropriate resource for that criterion or not. The analysis is based on a consensual decision about the correct votes. From the URLs, 93% were available at the evaluation of completeness, 92% at the evaluation of accuracy. The kappa values for inter-rater reliability were 0.83 and 0.36. The best service offers 60.8% of the pooled E-learning resources. The resources retrieved by the five criteria were rated as correct in 69.3% (LRSMed), 76.6% (KELDAmed), and 82.7% (CAL reviews). The overall accuracy was 76.7%. Medical students and other potential users of E-learning modules should be aware that the completeness of WWW-based catalogues in this area is not satisfying. The retrieval accuracy is better; four of five resources offered correspond with the search criterion. Up to now, most of the services miss an application-programming interface that could be used for a meta-search to improve completeness.

Despite the lost enthusiasm concerning E-learning a lot of material is available on the World Wide Web (WWW) free of charge. This material is collected and systematically described by services like the Learning Resource Server Medicine (LRSMed) at http://mmedia.medizin.uni-essen.de/portal/. With the LRSMed E-learning modules are made available for medical students by means of a metadata description that can be used for a catalogue search. The number of resources included has risen enormously from 100 in 1999 up to 805 today. Especially in 2004 there was an exponential increase in the LRSMed's content. Anatomy is still the field with the highest amount of available material, but general medicine has improved its position over the years and is now the second one. Technically and didactically simple material as scripts, textbooks, and link lists (called info services) is still dominating. Similar to 1999, there is not one module which could be truly referred to as tutorial dialogue. Simple material can not replace face-to-face-teaching. But it could be combined with conventional courses to establish some kind of blending learning. The scene of free E-learning modules on the WWW is ready to meet current challenges for efficient training of students and continuing education in medicine.

The concept of Diagnosis Related Groups (DRGs) is a well-established provider payment system for in-patient institutions. While the original aims of the system were to reduce costs as well as to increase quality and benefit of health care, the emphasis has progressively shifted to cost reduction, leaving the quality-oriented parameters in a secondary role. A major part of any patient-classification system is the pricing practice used to define the revenues for each patient group on the basis of single cases. To estimate the effects of different cost accounting methods on health care quality, we designed a new assessment system based on the employment of a WHO approach to compare different provider payment systems. The designed system is based on six different parameters recommended by the WHO: integration of patients' health risk into pricing practice, incentives for quality improvement and innovation, availability of high-class evidence-based therapy, prohibition of economically-founded exclusions, reduction of fragmentation incentives, and improvement of patient-oriented treatment. This assessment system enables the investigation of calculation processes of different patient-classification systems (and of provider payments in general), in view of their impact on quality.

The World Wide Web (WWW) promises many advantages in the distribution and presentation of electronic learning modules for medical education. However, there is a well-known obstacle: finding the right offers on demand. We developed a solution based on international standards called Learning Resource Server Medicine (LRSMed), which provides a meta-data collection of electronic learning modules. Based on the meta-data, LRSMed offers a service for the learners to retrieve WWW resources at the time of learning. We used the IMS Learning Resource Meta-data Information Model as suitable meta-data specification, the eXtensible Markup Language (XML) as syntax for interfaces and the Oracle suite for implementation. LRSMed is available at http://mmedia.medizin.uni-essen.de/portal/. More than 260 learning resources are currently registered and described. So far a user-interface has been implemented which allows searching, commenting and editing. In the next future we will add an application programming interface (API) for the integration of LRSMed in portals, learning platforms and information systems of hospitals, medical practices or healthcare networks.

Paper-based and electronic patient records generally are used in parallel to support different tasks. Many studies comparing their quality do not report sufficiently on the methods used. Few studies refer to the patient. Instead, most regard the paper record as the gold standard. Focusing on quality criteria, the current study compared the two records patient by patient, presuming that each might hold unique advantages. For surgical patients at a nonuniversity hospital, diagnosis and procedure codes from the hospital's electronic patient record (EPR set) were compared with the paper records (PPR set). Diagnosis coding from the paper-based patient record resulted in minor qualitative advantages. The EPR documentation showed potential advantages in both quality and quantity of procedure coding. As in many previous studies, the current study relied on a single individual to extract and transform contents from the paper record to compare PPR with EPR. The exploratory study, although limited, supports previous views of the complementary nature of paper and electronic records. The lessons learned from this study are that medical professionals should be cognizant of the possible discrepancies between paper and electronic information and look toward combining information from both records whenever appropriate. The inadequate methodology (transformations done by a single individual) used in the authors' study is typical of other studies in the field. The limited generalizability and restricted reproducibility of this commonly used approach emphasize the need to improve methods for comparing paper-based with electronic versions of a patient's chart.

Clinical guidelines can improve the quality of care in multiple trauma. In our Department of Trauma Surgery a specific guideline is available paper-based as a set of flowcharts. This format is appropriate for the use by experienced physicians but insufficient for electronic support of learning, workflow and process optimization. A formal and logically consistent version represented with a standardized meta-model is necessary for automatic processing. In our project we transferred the paper-based into an electronic format and analyzed the structure with respect to formal errors. Several errors were detected in seven error categories. The errors were corrected to reach a formally and logically consistent process model. In a second step the clinical content of the guideline was revised interactively using a process-modeling tool. Our study reveals that guideline development should be assisted by process modeling tools, which check the content in comparison to a meta-model. The meta-model itself could support the domain experts in formulating their knowledge systematically. To assure sustainability of guideline development a representation independent of specific applications or specific provider is necessary. Then, clinical guidelines could be used for eLearning, process optimization and workflow management additionally.

Background: The upcoming introduction of diagnosis related groups (DRG) as an exclusive base for future calculation of hospital proceeds in Germany requires a thorough analysis of cost data for various diseases., Objective: To compare the resulting combined cost weights of the Australian Refined DRG system (AR-DRG) with the proceeds based on actual per-day rates in stroke treatment., Patients and Methods: Between 1998 and 1999, data from 6520 patients (median age 68 years, 43% women) with acute stroke or transient ischemic attack (TIA) were prospectively documented in 15 departments of Neurology with an acute stroke unit, 9 departments of general Neurology and 6 departments of Internal Medicine. Prior to grouping cases into DRGs, all available data were transferred into ICD-10-SGB-V 2.0 or the Australian procedure system (MBS-Extended). Hospital proceeds for the respective cases were calculated based on per-day rates of the documenting hospitals., Results: The resulting cost weights demonstrate a good homogeneity compared to the length of stay. When introducing the AR-DRG with a uniform base rate in Germany, a relative decrease of hospital proceeds can be expected in Neurology Departments and for treatment of TIAs., Conclusion: Preservation of the existing structure of acute stroke care in Germany requires a supplement to a uniform base rate in Neurology departments.

Clinical guidelines can improve the quality of care in multiple trauma. In our Department of Trauma Surgery a specific guideline is available paper-based as a set of flowcharts. This format is appropriate for the use by experienced physicians but insufficient for electronic support of learning, workflow and process optimization. A formal and logically consistent version represented with a standardized meta-model is necessary for automatic processing. In our project we transferred the paper-based into an electronic format and analyzed the structure with respect to formal errors. Several errors were detected in 7 error categories. The errors were corrected to reach a formal and logically consistent process model. In a second step the clinical content of the guideline was revised interactively using a process modeling tool. Our study reveals that guideline development should be assisted by process modeling tools, which check the content in comparison to a meta-model. The meta-model itself could support the domain experts in formulating their knowledge systematically. To assure sustainability of guideline development a representation independent of specific applications or specific provider is necessary. Then clinical guidelines could be used for training, process optimization and workflow management additionally.

It is becoming increasingly common for health care providers to present information on the World Wide Web (WWW). Patients, as well as health care professionals, do not really know what they can expect today. Many quality criteria are proposed for the assessment of medical Internet sites focusing mainly on structure and content management. The objective of this study was to assess the quality of presentations by health care providers on the WWW and to detect strengths and weaknesses with regard to potential target groups, patients, colleagues, and students. A sample of 171 presentations was randomly selected in March 2000 from a collection of 469 surgical departments in Germany. Medical doctors undergoing a full-time training in medical informatics rated the presentations. A previously evaluated questionnaire was used to assess the presentations with regard to 12 criteria about content and technical features. For each criterion the categories 'very good', 'sufficient', and 'insufficient' could be used. Twenty medical doctors assessed 168 presentations with one to seven valuations per presentation. Three presentations could not be accessed at the time of evaluation. Sixty-eight per cent of the median values of each criterion were rated as insufficient. The only criteria rated sufficient or better in at least 50% were: employees/map, survey of offered medical services, navigation, and layout. University hospitals and heart centres achieved significantly better results than regional hospitals. In conclusion, the quality of provider information on the W WW is unsatisfactory. Most surgical departments do not provide information that could help patients to choose their physicians. The criteria set developed here could be a useful tool for a target-group-oriented self-assessment of provider presentations on the World Wide Web.

An increasing number of surgical departments is creating its own home-page in the World Wide Web (WWW). We investigated 184 presentations concerning their quality in content and technical realization. Our research revealed that most presentations regard patients as their main target group in order to meet the patients' demand for information and transparency. However, universities are especially concentrating on scientific development and neglecting the patients. Only a few presentations contain means for web-based training. In general, technical realization seems to be much better than the content itself. As patients tend to appear as customers who will choose the hospital they feel comfortable with, every clinical department that is a competitor should create a communication and information base for their customers. Thus, they will be able to keep in touch, present their treatment types and to enable patients to compare a multitude of surgical departments. The usefulness for colleagues or cooperating institutions must be improved. The WWW has become an important center of information in surgery.

The definition of German case groups now uses an adaptation of the ICD-10: ICD-10-SGBV. For the transformation of the existing ICD-9-based definition into the ICD-10-SGBV an ICD-9/ICD-10 conversion table was used. The derived raw definitions were manually refined in detail. Due to the transformation of the classification system, the number of definitions increased immensely, as the ICD-10 SGBV is by far more detailed than the formerly used ICD-9. In our opinion, ICD-10 SGBV is not ideal for the definition of case groups, because this classification system is designed to support statistics on morbidity and mortality, but definitions of case groups are oriented to cost factors. Therefore the definition of case groups should be based on a specially designed classification system or one should reassess the necessity of a parallel definition by codes of classifications as well as by text. In both alternatives the introduction of a detailed and systematic medical documentation with expressive terminology systems will offer the advantage of classifying patients into medical oriented classifications as well as case groups.

Motivated by economic and quality management issues, many hospitals strive for the introduction of information systems into the clinical environment. To introduce the most suitable software product, a systematic selection procedure is required involving all affected staff. The paper describes a methodology that guides the clinical users to an objective motivated decision. This semi-formal methodology is necessary in view of missing standard models for the description of hospital information systems and leads to high acceptance in practical use. The methodology consists of structured product demonstrations with a quantitative assessment, benefit-value-analyses based on step weights for the functions needed, and test installations. Prerequisite of this procedure was the definition of objectives and priorities in a standard catalog that was used as reference in the whole project. Selecting a software product following this systematic procedure establishes a sound basis for a successful application in the clinical environment.

Our first generation hospital information system is in routine use since 1989. The patient data are used for multiple clinical purposes: operation scheduling, reminder for patient care, case retrieval for research and education, and so on. The computer-based patient record was complemented by a flexible PC-based query and report facility for quality management. A regular export of patient data from the host is translated into a relational database model and assessed via the standard of Open Database Connectivity (ODBC) by a statistical analysis tool. Herewith, descriptive and analytical statistics become available to support the clinical departments in patient care. Concerning the migration of first generation systems to modern architectures the presented approach has to be compared with strategies of replacement and capsulation. A decision on the strategy applied should take into account local resources and opportunities.

Today different classification systems are used in Germany for the standardization and coding of surgical procedures. On January 1, 1995, the German Minister of Health introduced a new classification system called "Operationenschlüssel nach section 301 SGB V" (OPS-301) for surgical procedures performed in hospitals. The standardization by the OPS-301 is limited to inpatients. In outpatient care, surgical procedures are coded by two billing systems: EBM and GOA. Thus, the situation is characterized by coding systems that are used in parallel which are to some extent incompatible. This leads to avoidable workload and lower quality of the documented data. The general goal is the development of a new classification system which on the one hand should be able to provide different views depending on the questions. On the other hand the system should integrate the different views through a clear and consistent structure of surgical procedures.

Based on the algorithm of defined combinations between diagnosis and surgical procedures due to the Gesundheitsstrukturgesetz an automatical detection of reimbursement with an electronic hospital information system is presented.

A retrospective study about the impact of different quality control methods for medical documentation was performed at the Surgical Center II in Essen. The standardized medical documentation was legislative obliged since the first of 1996 and includes diagnoses and surgical procedures. The patient data were taken from the computer-based patient record of the Surgical Center II which is in routine use since 1989. Quality improvement was aimed at with lectures, training, a quality circle, and systematic approaches like feedback and reminder between 1995 and 1996. The results demonstrate that information and training of physicians is significantly less important for the quality of documentation than a departmental and central control. It is advisable to take this results into account introducing new documentation entities and procedures and to provide functionalities for a periodical control soon.

The development of open and integrated knowledge bases makes new demands on the definition of the used terminology. The definition should be realized in a data dictionary separated from the knowledge base. Within the works done at a reference model of medical knowledge, a data dictionary has been developed and used in different applications: a term definition shell, a documentation tool and a knowledge base. The data dictionary includes that part of terminology, which is largely independent of a certain knowledge model. For that reason, the data dictionary can be used as a basis for integrating knowledge bases into information systems, for knowledge sharing and reuse and for modular development of knowledge-based systems.