Group-wide collaborations

Successful treatment of complex diseases like cancer requires expertise and know-how from many departments and specialists.
However, the patient’s welfare is not dictated by medical skill alone. The physician cannot take prompt and appropriate action unless the necessary patient data is available in the right place at all times.

Vivantes is Germany’s largest community hospital group. Every year, some 15,000 employees provide care to over 500,000 in- and outpatients. In addition to hospitals, the group comprises nursing homes with about 2000 residential places, healthcare center (MVZ) branches with a total of about 110 physician posts, specialist practices, an outpatient rehabilitation facility and a hospice. This has moved Vivantes along the path to becoming a comprehensive healthcare provider with a cross-sectoral focus. The hospitals, MVZ and rehabilitation clinic are each operated as separate legal entities in the form of limited liability companies. This has significant consequences in terms of the regulatory requirements, which derive for the most part from privacy laws and medical professional secrecy in accordance with § 203 of the German Criminal Code (StGB). Each legal entity needs to have a stand-alone data management system that is cleanly separated from the others. In the process of building a group-wide IHE infrastructure, this means that separate affinity domains must by necessity be set up for the individual facilities, each with its own master patient index (MPI), document registry and document repositories.

This is a challenge, and completely at odds with the current practice of interdisciplinary, cross-sectoral treatment of complex illnesses involving numerous entities.

PATIENTS CANNOT GET THE BEST POSSIBLE TREATMENT UNLESS THEIR DOCTORS HAVE ALL THE INFORMATION AVAILABLE.

In order to provide the patient with the best possible care, it is absolutely necessary to make the information, data, and images needed for a particular decision situation accessible to all the stakeholders involved in the treatment process at all times and at a high quality level. Vivantes therefore investigated the available options for a multi-affinity domain architecture to deliver virtual master patient records for the clinicians. It was vital for the solution to meet the following criteria:

  • Guaranteed data protection compliance
  • Scalability, i.e. the ability to manage even large amounts of data and transaction volumes
  • Ability to manage the solution efficiently and evaluate the organizational structures needed to do so (e.g. clearinghouses for MPI maintenance)

Before a doctor can retrieve medical data from a different IHE affinity domain, the patient must give consent and the patient identifier from the other affinity domain must be known to the system. There are several ways of handling this. One solution is a higher-level MPI that links all the patient numbers in the various affinity domains. This is the principle behind the ELGA (Electronic Health Record) in Austria, where there is a nationwide MPI. There are no plans for this type of model in Germany, and building hierarchical MPIs on a regional basis is cost-intensive, in addition to being impracticable because of the numerous different cooperations it would entail. The second possibility is to network federated MPIs. This is the strategy used by eHealth Suisse to create electronic patient dossiers in Switzerland. The IHE’s XCPD (Cross-Community Patient Discovery) profile provides three different options for federated architectures to exchange patient numbers between various affinity domains:Before a doctor can retrieve medical data from a different IHE affinity domain, the patient must give consent and the patient identifier from the other affinity domain must be known to the system. There are several ways of handling this. One solution is a higher-level MPI that links all the patient numbers in the various affinity domains. This is the principle behind the ELGA (Electronic Health Record) in Austria, where there is a nationwide MPI. There are no plans for this type of model in Germany, and building hierarchical MPIs on a regional basis is cost-intensive, in addition to being impracticable because of the numerous different cooperations it would entail. The second possibility is to network federated MPIs. This is the strategy used by eHealth Suisse to create electronic patient dossiers in Switzerland. The IHE’s XCPD (Cross-Community Patient Discovery) profile provides three different options for federated architectures to exchange patient numbers between various affinity domains:

1. Demographic Query Only Mode:
Patients in another affinity domain are queried based on demographic information only. Depending on how specific the query is, the hits may include multiple patients. From a data protection perspective, there are risks involved in the disclosure of information belonging to patients who come up as “false positive” hits, which is a major drawback of this option.

2. Shared/National Patient Identifier Query and Feed:
Queries about patients in a different affinity domain are based not on patient demographic data but rather on a shared or national patient identifier, such as the patient’s insurance number. However, not every patient in Germany has an insurance number, and numbers are not unique to individual patients over their lifetimes, so this option has its limitations.

3. Demographic Query and Feed:
Queries include both demographic data and the patient identifier from the initiating affinity domain. This allows the queried domain to compare the patient with existing patient datasets and record the match. The matching process can return a response to the querying affinity domain (with a deferred response option), which can then make the same match. Unfortunately, match management is limited, as changes in patient information are not relayed.

Gunther Nolte: “International standards and profiles provide investment and future security.”

 

Conclusion:
Cross-facility and cross-network patient care calls for interoperable solutions that bring together all the patient medical data needed for treatment in the form of a virtual master patient record for the treatment teams. International standards and profiles lend themselves as a basis for solutions of this kind. They provide investment and future security and enable economically viable solution implementation. IHE offers a series of approaches that can be implemented flexibly according to needs and environment. To further standardize the use of IHE profiles, IHE Germany has established a number of working groups to develop interoperable solutions for various application areas, such as digital archiving.