Die technische Implementierung eines EDV-gestützten Prozessdokumentationssystems für den Routineeinsatz in der stationären medizinischen Rehabilitation (RehaProDok)

Abstract

Since 1994 the German Pension Fund has developed a systematic and centralized quality control system. Central components are a structural analysis of hospitals and rehab centers, a peer review instrument based on the treatment protocols and reports, and an outcome questionaire based on a follow-up 6 months after discharge from hospital or the rehab center. In order to improve the well established peer review instrument a new protocol document named RehaProDok was established. Based on a preexisting electronic report system, the new document can be generated automatically. Without additional work for the hospital or center a short discharge report for physicians is produced with this instrument. The use of ICF is strengthened by standardized use of rehab goals and its systematic input into the final report, which in turn improves patient orientation. Other quality important features (e. g. Team approach, changes in therapy protocol due to progress within of the rehab process) may be examined directly and added in the future. All technical improvements can be easily adapted to other clinical information systems.

The International Classification of Functioning, Disability and Health (ICF) in Electronic Health Records

“…The other one was a publication found during the search for literature published by a research group named during the ICF expert meeting. Consequently, 17 articles were included [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50].…”

“…Information Quality: Across publications, it was highlighted that the comprehensiveness and focus of the ICF's conceptual model allow going beyond a purely medical perspective towards a biopsycho-social understanding of health [34][35][36][37][39][40][41][42][43][44][45][46][47][48][49][50]. The universal and interdisciplinary language of the ICF, which can be applied in different healthcare settings, by different professions, and across countries, was also highlighted as a benefit of using the ICF [34, 35, 39, 41, 43-46, 48, 50].…”

“…Such a standardization fosters interoperability and comparability across information systems, and ultimately strengthens data quality. Though the comprehensiveness was stated as a strength of the ICF, the majority of publications also pointed out the necessity of selecting a reduced number of ICF codes for the ICF to be feasible for coding in clinical practice [36][37][38][39][40][41][42][43][44][45][47][48][49][50]. Various approaches to reducing or selecting codes were suggested, such as automated code selection through natural language processing [34,37,40,45].…”

“…System Quality: Some of the themes that emerged with respect to system quality were more general, others were specific to the ICF. The general themes referred to the necessity of implementing and ensuring compatibility of various information standards [34, 36-38, 44, 46, 49] and to data safety considerations [36,38,[42][43][44]49]. Examples include authorization for information access [36,42,44], or the requirements for a database environment [35, 36, 38, 41-43, 48, 50] that can be used to visualize and represent meaningful information to patients in the clinical encounter [36,37,39,41,43,46].…”

“…Service Quality: Limited reference was given to Service Quality in the identified papers. Three publications referred to the internal IT services that technically supported the implementation of the ICF in EHRs [37,38,42], e.g. outlining how expenditures were kept low through the implementation of new features in EHRs [42].…”