[Experiences in introducing and using a patient data management system (PDMS). in anesthesiology at the Clinic of Anesthesiology and Intensive Care Medicine of the University of Leipzig].

Abstract

In the field of anaesthesia the demands on the quality and quantity of documentation are increasing constantly. Patient Data Management Systems (PDMS) have proved an effective means of handling the volume of data generated. The main reasons for introducing a PDMS vary greatly, nevertheless, it is possible to formulate general requirements such as those of the "Position Paper of the Study Group on Patient Data Management Systems (PDMS) of the University Departments of Anaesthesiology in Bavaria". Although these requirements are very broad, they provide a good basis for comparing different approaches to computer-assisted documentation in anaesthesiology. The stage currently reached at the Department of Anaesthesiology and Intensive Care Medicine (KAI) of the University of Leipzig is analysed in comparison with the position paper. The COPRA system was established at KAI Leipzig eight years ago. It was developed from an existing version for intensive care medicine. It meets the demands made on it when it was introduced and can be enlarged and adjusted to the special needs of anaesthesiology. One particular requirement was that it should be possible to handle computer-assisted documentation and conventional documentation on paper simultaneously. This requirement is met by making the printed forms and those shown on the VDU practically the same in appearance. The anaesthetist is able to recognize "his" record on the screen. This greatly reduces the time required for familiarization and training. If possible, the orientation and updating of the system should be in the hands of an anaesthetist, since this is the only way to ensure that it remains geared primarily to medical needs. Administrative aspects have to be taken into account, but they should not dominate the system. The anaesthetist managing the system should have some basic training in EDP, or at least take a special interest in it. This ensures that minor enlargements can be carried out easily, as soon as required. Proper, expert evaluation of the compiled data requires both a knowledge of medicine and anaesthesiology and an understanding of how information is presented in an EDP system. Enlargements of the system resulting from increasing documentation obligations and quality assurance can be integrated smoothly. In its current form the system is able to depict all parts of the specialist field with the same user interface. By systematically meeting general requirements and taking the special needs of a hospital into account, it has been possible to create a flexible electronic documentation system covering all areas of the anaesthetist's work.