Electronic Health Record: Transparent Patient?

A smart hospital has many components, which ultimately come together as a connected whole, thus achieving better patient care. One crucial piece of the puzzle that some countries like the U.S. have implemented but one that’s still missing in Germany is the electronic health record (or electronic medical record). It is shrouded in controversy and yet a critical aspect of the hospital of the future.

The countdown is on. Germany’s Federal Minister of Health Jens Spahn is putting pressure on stakeholders. Beginning in January of 2019, things are expected to ramp up in Germany. That’s when Germany will move one step closer to the smart hospital concept and follow in the footsteps of its neighbor Austria and smaller European countries such as Estonia, as well as the United States of America. The latter decided a long time ago to collect patient data and take advantage of the advancing digitization in the medical sector. Starting next year, according to the Terminservice- und Versorgungsgesetz (TSVG, English: Appointment Service and Care Act), the electronic health record (EHR) - an important part of networked healthcare - will consolidate all data still in decentralized storage in various medical offices or hospital management systems.

The goal: All patient records will be digitally stored in the cloud in the future and can be directly accessed during office visits or hospital stays. The idea sounds reasonable and marks an important component of the "smart hospital" framework, which is designed to ensure better patient care through digitization, integration, new smart technologies, and innovations. But are things really that easy?

The idea is to collect different types of information in the digital cloud pertaining to the patient’s clinical picture: diagnostic findings, allergies, prescription data, laboratory data, x-rays, electrocardiograms, and medications.

This results in benefits for the treatment and care of patients. Attending physicians have direct access to this information, making duplicate exams and redundant testing potentially a thing of the past. Especially when it comes to emergencies, a quick look at the virtual database will be valuable because hospital staff can immediately learn about a patient’s pre-existing conditions and drug allergies. What’s more, research can also benefit from this impending approach, allowing it to see the big picture.

Patient data can be analyzed by using statistical methods that can lead to better preventive health care - think "big data". For patients, their own medical history becomes more transparent. Patients also get to decide whether they want to use a so-called EHR (German: ePA) and what it should look like. This also pertains to the information that can be stored in it, including who has access and who is allowed to use it.

That being said, there are still questions concerning the technical implementation of the electronic health record. Estonia is a pioneer when it comes to digitization. It has introduced the digital cloud in 2013 and not everyone has access to it. Only people with specific authorization can access the stored data. In the U.S., the electronic health record so far only applies to patients covered by government health insurance programs. Patients under private (non-government) health coverage are exempt from these regulations. There is no standard model for the Federal Republic of Germany at this point, though there are three conceivable versions. First, there is the AOK model: Patient data stays with the respective doctor, while a copy is also stored with the health insurance company or on a server, where all information can be consolidated thanks to a search algorithm. The system follows the example of countries such as Austria and Estonia. Another health insurance company - the TK or Techniker Krankenkasse - has teamed up with IBM GmbH and health insurance providers Generali and Signal Iduna to create "TK-Safe". Based on the new EU data protection guidelines, the data is also meant to be stored on certified servers. The TK health insurance company is said to not have direct access to the information. The system has been in its initial testing phase for the past few weeks. The third option would be an app. In this case, the insured person always carries his/her health record in his/her pocket. This particular option is favored by most German health insurance companies – including Allianz and DAK.

Meanwhile, there is some criticism from physicians. Their concern: How is data protection ensured as it pertains to doctor-patient confidentiality? After all, aren’t handwritten records far more detailed and relevant? Since the patient still has the decision-making power over the data storage, crucial information might not be recorded, thus limiting the benefit of the health record. This would result in misdiagnoses, medical errors and bad medical consultations. Data entry mistakes are also a concern. Yet another point of contention is the fact that the health insurance provider has simultaneous access to the database (as part of the AOK model). Meanwhile, medical offices and hospitals do not want to share all their information.

While the Health Insurance Portability and Accountability Act has been regulating electronic data processing in the U.S. since 1996, three years ago, some of Germany's next-door neighbors have already decided to fully digitize patient information and consolidate it in a database. In Austria, the electronic health record "ELGA" has been implemented since 2015 in hospitals in the Styrian region, in church-affiliated hospitals and centers for geriatric care, as well as five departments of the Vienna-Hietzing Hospital. On May 18, 2016, "ELGA" made its debut at the Vienna General Hospital. Patients who don’t consent to the system can limit and completely deny access by opting out.

Needless to say, many aspects still need further clarification. To ensure quality, safe and seamless care of patients - especially in hospitals- all stakeholders would first have to agree on standardized data storage. Meanwhile, the goal of better patient care could be much easier and faster achieved with the data that becomes available to physicians thanks to the electronic health record.