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e-Health and Evidence-Based IT

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Germany has one of the world’s leading health care systems in terms of patient’s safety, outcome quality and process performance. Having high standards in diagnostics and therapy, high patient safety standards and one of the world’s highest environmental standard, goes hand in hand with one of the highest standards in privacy and data-protection.

The right to informational self-determination is a fundamental right and explicitly stated in the German Constitution as a basic law. This leads to a generally accepted and respected handling of patient data with the highest precision in German hospitals. The German Data Protection Act can be regarded as one of the most restrictive worldwide. The German patients and international medical tourists therefore enjoy the highest quality of data protection.

Germany has 2,139 hospitals with 1.1 million people employed with a sales volume of about 60 billion Euro (84.7 billion $). In Germany 421,686 physicians are admitted of which 153,800 are working in hospitals and 138,300 doctors are working in ambulant medical care. In Germany, operating physicians have an obligation to continuous medical education.  High quality in medical performance combined with continuous education, high-tech medical equipment, safety and hospitality has lead in an increasing number of medical tourists in the last few years.

One of the reasons of high performance of the German health care system is the strict obligation to quality and a long experience in medical informatics, telemedicine and e-Health. Practically all German hospitals, medical practices and pharmacies have medical information systems and are interlinked with each other and with health insurances.

An increasing number of health care providers join together to regional health care networks for resource and knowledge sharing. Germany has over 80 health care regions in which collaboration is supported. This leads to better communication and avoidance of duplicated examinations with the result being higher quality and safety at lower cost.

The application of information technology (IT) in all health care organizations has become a complex process. For a long time, IT was only used in administration, but German hospitals with modern management recognized the potential of the optimal use of IT in all forms of service provision and established hospital information systems early on.

Almost every hospital in Germany runs a hospital information system following international standards in data communication like HL7 (health level 7), DICOM (digital imaging and communication in medicine). The degree of IT penetration in medical process in German hospitals is very high.

One of the reasons for this high integration of electronic medical records is the introduction of the DRG-system (diagnosis related groups) in the year 2004. The DRG-system is the governmental basis for the accounting of medical treatment in German hospitals.

The Electronic Health Card

Next year the majority of the compulsory health insured German patients will get a new electronic health card for the secure access to medical information. A new telecommunication platform with secure data connectors in hospitals and medical practices helps to build local networks between GPs, hospitals, pharmacies, health insurance organizations and a nationwide secure access system for the exchange of medical information. But IT-based medical documentation cannot only reduce costs, but it can increase the quality of the processes and the outcome for patients.

Well-organized IT solutions, like minimizing transportation times by avoiding paper documents or the parallel use of data by different users, can cut costs and rise quality. High quality treatment needs instantly available relevant information. In the USA, for example, 522,000 incorrect prescriptions for medication could be avoided by consistent IT printout and/or transmission of physician’s orders, as the supply and administration of medication in a clinical setting undergoes many clinical and administrative steps.

According to a study sponsored by Microsoft , approximately 70% of the transactions in the American health care system are based on paper forms, in other words, 20 cents of every dollar spent on administrative costs is for paper forms. The economic feasibility of many institutions in the health care system today depends directly on the quality of their documentation and the availability of information and, therefore, also on the optimal application of IT.

These problems provided the incentive for David Sackett to develop methods in the field of medicine to solve the problem of floods of worthless information with the concept of evidence-based medicine over 15 years ago.

Evidence-Based Information Technology

As a holistic approach, EbIT (evidence-based information technology) combines evidence-based information from different specialties, like evidence-based health care (EbHC), and implements these solutions in the IT structure of the respective organization.

The integration of these principles into hospital information systems, intranets, or evidence-based guidelines in clinical pathways brings added value to the organization which can be measured with reference numbers and can contribute to the development of the organization and its long-term success. Figure 1 shows EbIT as a concept for the transfer of solutions into practice with simultaneous assessment of its usefulness.

1Birkmeyer, J. D., Birkmeyer, C. M., Wenberg, D. E., & Young, M. (2000, November). Leapfrog patient safety standards: The potential benefit of universal adoption, TheLeapFrogGroup for Patient Safety, p. 1. from

2Rainzer, W. (2003, April). The use of IT could save 5-8% of costs. Krankenhaus-IT-Journal, 64.


The application of the methods of evidence-based medicine in IT processes can improve access to information in a hospital; improve the quality of the information, and save costs.

The Concept

The conception and implementation of EbIT proceed from the following assumptions:

1.Information processing is a key technology for organizations in the health care system, which has hitherto received too little attention:

  • Applying this key technology could reveal additional potentials for cost reduction and improve the quality of service.
  • An effective and efficient use of IT requires a modern form of organization.
  • Standardizing information processes can improve their quality and reduce IT costs.

2.    Implementation of EbIT requires a “learning” organization:

  • Continuous online requests for feedback provide a good assessment of the acceptance of IT solutions among the users and management.
  • Documentation of suggested solutions helps create a knowledge base and promotes the accumulation of useful information.

Since information constitutes an indispensable factor in the production and supply of medical services, it is only logical to organize the process of information provision according to the rules of evidence-based medicine (EbM). The supply of information for treatment procedures must fulfill certain requirements.

The user of an IT system evaluates the usefulness of the provided information according to its relevance (R) and validity (V) and the time and effort (E) required to receive the information. If the user has to wait too long for the information, the acceptance and usefulness of the information decrease because the situation demanding information might have changed, especially in an international context.

Many communicating partners are involved in the treatment of a patient in an international or cross border context, all of whom require information. It is not uncommon that, together with physicians, nursing staff, therapists, relatives, administration, health insurance providers, and other stakeholders in the treatment process, a large number of communicating partners must be included in the IT solution quickly.

Managing the interfaces presents a large problem because IT systems from different manufacturers and suppliers must be coordinated as the following figure illustrates.

shows the complex interactions of medical treatment in an international context.

Evidence-based medicine (EbM), together with evidence-based nursing (EbN) or other disciplines which combine internal and external evidence, are like parts of a building whose roof is evidence-based information technology (EbIT). Without this edifice of valid and relevant information which reaches the right service provider in the health care system in the right place at the right time, it will be difficult to achieve safe, effective, and patient oriented treatment.

The concept EbIT thereby provides a holistic approach to the supply of information in the treatment process and the related secondary processes.

Information plays an essential role in all evidence-based concepts. It is the task of IT to transport information in an appropriate manner, that is, at the correct time to the correct place and to the correct user securely and reliably.

The solution of an IT-related user problem should itself be fashioned on evidence-based rules. That this is not always the case is demonstrated by dissatisfied users, overspent IT budgets, and problems in the quality of information provision.

Classical implementations of hospital information systems are closed systems with few standard interfaces. The role of the patient in these systems is very limited. Most of the health information is provided by the doctor.

With the growth of Web 2.0 – the web of collaboration – the user has a new role; he is the producer and the administrator of the content. The same development transfers personal health information to PHR (personal health records) under the control of the patient.

Medical information is stored at different places in different hospital information systems. Only parts of the medical information are exchanged between the providers. The process of medical information exchange is doctor driven.

Microsoft’s health vault ( and Active health Management

( are examples of a Web based PHR. In these systems the patient initiates the input and transfer of personal health information. In additional to medical information, the patient can manage his sports or dietary habits from smart systems like body area network and home care systems, the family medical history or advance directives and living wills.

Patient and health care providers store medical information together in a central medical storage managed by a trusted third party. The trusted third party could be a company of trust or a governmental organization. That would be an honorable task for the WHO (World Health Organization).

How could a modern IT-system for collaborative health care support with evidence-based medical pathways look like?  The structure and components of modern IT-support in health care management is shown in the following figure.

Components and structure of a modern IT-infrastructure for international health care

Family relationships, company environment and social system are important surrounding factors for the provision of health care including the patient’s knowledge about his health condition and the resources for prevention. The medical treatment process and aftercare are also based on medical information and the sharing and access to data over international borders.

Processes in general have degrees of maturity. Process can be managed and controlled. In medical treatment the outcome is controlled by the doctor, the patient and economically controlled by the health insurance and the patient. Modern IT-systems can offer decision support by benchmarking and ranking huge amounts of data.

Techniques like data mining are very common in business IT-systems. The retrospective analysis of anonymous health care records can lead us to a proactive health care management where the patient and the doctors are supported and informed by the virtual health information system.

Automated processes can make benchmarks and an analysis of individual health information which can help to provide risk analysis. So the virtual personal health system represented can advise the patient of personal risks and can give evidence-based information and guidelines for patients and doctors.

Virtual personal health information is available from every place in the world. The medical treatment and post treatment processes could be eased by a collaborative system between patient and doctors in the home county and in the country where the treatment takes place.

The patient and the doctor are informed and supported by the smart appliances and have a secure access to quality-assured health information. The decision-support features of the virtual personal health records help the patient to find adequate medical treatment abroad or at home. Health is too important to be managed like a patchwork from providers with a lot of barriers.

The next generation health management systems must be secure and patient-driven, offer decision-support, risk-management and community-building and must enable the user (patient and doctor) with online data analysis and online access to evidence-based information.

All health care systems can increase the quality of processes and cut costs through consistent and optimal use of IT by avoiding redundancy and inconsistency. A combination of procedural optimization and integrated IT application can change IT structures that are segmented and fragmented into a cooperative structure which is characterized by agreement, functionality, and transparency.

If the fundamental IT processes already function according to the rules of evidence-based information processing (EbIT), a transparent data-driven IT system ensuring high satisfaction among those who run and use the system can be achieved through continuous optimization.

Modern and sophisticated IT-systems have the potential to support medical treatment and help to ensure quality in all processes. Web based personal health information with evidence-based knowledge support and proactive health management is the key to optimal healthcare provision, particularly in an international context.

Understanding the dynamics of IT-process in international health care is a vital management competence for doctors and hospital managers. The comprehension and ability to work in modern IT-based communication and collaboration structures is a key competence in international management and essential element of the MBA curriculum at Deggendorf University.

Prof. Dr. Horst Kunhardt has University degrees in computer science and human biology. He is Professor at the Deggendorf University. His areas of teaching are information application systems and health care management. He is academic programme coordinator for an MBA Health care Management and has 15 years experience as CIO and quality manager at the Mainkofen District Hospital. Dr. Kunhardt has significant expertise as project manager in building healthcare networks and member of the scientific advisory board of several health care companies.  He may be contacted through the University of Applied Sciences Deggendorf and .

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