ELGA and networking: A look behind the scenes

The Electronic Health Record (ELGA) has been in use by the Lower Austrian Provincial Clinics Holding (NÖ Landeskliniken-Holding) since January 2017. Physicians and patients can access reports anywhere in Austria, which saves a great deal of time. This puts outpatient and inpatient lab results, imaging reports, discharge letters from hospital stays, etc., at their disposal.

All 27 clinic locations have been brought together under the umbrella of the holding company since 2008. This large number of actors inevitably brings with it a heterogeneous IT landscape, which is evident from the hospital information systems (HISs): Those 27 locations use HISs from five different manufacturers, each with a different configuration and architecture.

The 27 HISs use IHE mechanisms to import ELGA-related XML documents (CDA 3) into the ELGA domain of Lower Austria. In each individual case, a situational opt-out (SOO) function is stored for that patient. Discharge summaries are created directly in the HIS by physicians and nursing staff, but radiology and lab reports are generated in their respective subsystems, from which they can be transferred to the HIS.

Orchestra as the communications server

The Lower Austria Regional Clinics Holding chose Orchestra, a centrally operated communications server made by soffico. Systems were integrated selectively at first, but then the application field was expanded based on positive experiences. Orchestra has since become the central communications server for medical data streams, with new subsystems being added regularly. The reasons for this strategic decision are obvious:

  • Central applications are necessary because of technical requirements (bundling of data streams, conversion logic).
  • Federal state-wide IT operations are backed up by uniform service level agreements (SLAs). Record networking quality can be enhanced by means of central monitoring in a 24/7 service framework.
  • Multi-connected systems of similar types lead to considerable synergy effects in terms of license and service costs.

Experiences and challenges

In addition to the usual technical challenges, there are also organizational tasks to be dealt with:

Integrating proprietary systems

Clinical workflows need to be taken into account when transmitting data, or else redefined with the clinics’ participation, for example when using report mailboxes or compiling cumulative reports from measured values. Tried-and-true older systems from smaller manufacturers are a special case and are employed as specialized systems for a few use cases.

Uniformity through intelligent data transformation

To achieve uniform transfer of data throughout the region to a shared medical record, messages must be standardized across the enterprise in terms of content (medical and nursing care-related)—even beyond the HL7 standard. The challenge here is to create consensus among the relevant committees within the overall organization as to which catalogs and workflows will be used. One example of this is the LOINC catalog of laboratory services for Lower Austria. It is valid for the entire federal state of Lower Austria and is used with the centrally operated laboratory test platform. Standardized central medical applications are labor-intensive, yet straightforward; still, it is unrealistic to try to achieve uniformity in all the subsystems for the various disciplines. Data transformation (static mapping in the simplest cases) can be used to intelligently adjust for any differences.

ELGA: National guidelines vs. real-world workflows

The content of any CDA 3 report is clearly defined by the ELGA. This makes reports consistent at the national level. Within Lower Austria, on the other hand, clarity is still needed regarding real-world processes. For example, in many clinics the physicians have more comprehensive reports available to them during ward rounds, such as PDF lab reports with added graphics. Standardized solutions like a style sheet modified for use in Lower Austria—e.g. for displaying CDA 3 documents or transferring PDF lab reports to the HIS—require coordination across the whole province.

Even high-tech IT projects are organizational projects.

Maintenance-free operation

As each new system is integrated, coordination and communication regarding maintenance windows becomes more difficult. Maintenance of the communications server was initially limited to central applications, and thus to a few departments. The subject of freedom from maintenance becomes progressively more important as the number of subsystems increases. Work goes on in this area, because ultimately it is the key to acceptance among the clinical users.

Lessons learned

Even in a field as technical as data integration, organizational issues play a major role.

  • The organizational processes have to be adapted for each clinic, and there are questions to be answered, e.g.: How can I provide 24/7 service? And how can I create centrally coordinated maintenance windows?
  • New standards apart from the HL7 standard are needed and require coordination across clinics. This applies in particular to conversion to an ELGA-compliant CDA 3 report.