The electronic patient record – a companion for life
Data and diagnoses can be stored in the electronic patient record (ePA) from birth. The ePA is useful in sickness and in health – the electronic storage of documents like the edental bonus booklet or certificate of vaccination means that you never have to worry about losing them or forgetting to take them to appointments.
Shortly after Vera’s birth, her parents create an electronic patient record (ePA) for their newborn daughter. It includes a child examination booklet and e-certificate of vaccination, in which the results of her pediatric screenings (U check-ups) and vaccinations are recorded. When Vera is a little older, she begins to sneeze whenever she strokes her friend’s pet cat. The family doctor examines Vera and refers to her an allergy specialist. The allergy specialist tests whether she has an animal allergy. Vera’s parents grant their family doctor and the specialist access to the relevant diagnoses in the ePA. The results of the examinations are now available to both doctors. This allows them to provide the best care possible and take a holistic approach to treating Vera. Vera visits the dentist twice a year. These regular check-ups are documented in the electronic dental bonus booklet in the ePA. A really practical benefit is that the e-dental bonus booklet can’t be left at home by mistake. If the dental practice is granted access to the ePA, details of each check-up can be recorded in it. Subsequent vaccinations, such as the booster polio vaccine or the vaccine to prevent cervical cancer, will also be stored in the electronic certificate of vaccination. As the electronic certificate of vaccination cannot be lost, this avoids any gaps in Vera’s vaccination record, as well as duplicate immunizations. After an accident while playing sports, Vera is treated in hospital for a few days. The hospital discharge letter, together with details of her diagnoses and treatments, is added to the ePA – where it can be accessed by her family doctor and by the orthopedic specialist she will see for follow-up treatment. An electronic sick leave notice (eAU) is automatically sent to Vera’s health insurance provider and employer. This is also stored in the ePA. An entire lifetime of diagnoses are permanently stored in the ePA. This means that, even years later, Vera can still look back and see which bones were injured in the accident and what treatment she received. Vera also allows her maternity record to be maintained electronically in the ePA. This means that her family doctor, midwife and gynecologist can, between them, provide her with all the support and care she needs during pregnancy. For example, her gynecologist can check the ePA to make sure that she has been vaccinated against rubella. Later in life, it is detected that Vera has high blood pressure and her cholesterol level is also slightly elevated. She is prescribed medication for both conditions. These details are entered in the electronic medication treatment plan and the ePA, so that all doctors treating Vera can more accurately assess whether any drug interactions could occur – for example, with the inhaler that the allergy specialist has prescribed for her. In older age, Vera finds it more difficult to take care of everything herself, so she asks her son Sascha to act as her representative and transfers the task of managing her ePA to him. He makes sure that all important test results, diagnoses and changes to prescriptions continue to be stored in her ePA. In this way, everyone involved is always up-to-date.