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Introduction: Optimized workflows and communication between institutions involved in a patient's treatment process can lead to improved quality and efficiency in the healthcare sector. Electronic Health Records (EHRs) provide a patient-centered access to clinical data across institutional boundaries supporting the above mentioned aspects. Interoperability is regarded as vital success factor. However a clear definition of interoperability does not exist. The aim of this work is to define and to assess interoperability criteria as required for EHRs., Methods: The definition and assessment of interoperability criteria is supported by the analysis of existing literature and personal experience as well as by discussions with several domain experts., Results: Criteria for interoperability addresses the following aspects: Interfaces, Semantics, Legal and organizational aspects and Security. The Integrating the Healthcare Enterprises initiative (IHE) profiles make a major contribution to these aspects, but they also arise new problems. Flexibility for adoption to different organizational/regional or other specific conditions is missing. Regional or national initiatives should get a possibility to realize their specific needs within the boundaries of IHE profiles. Security so far is an optional element which is one of IHE greatest omissions. An integrated security approach seems to be preferable., Discussion: Irrespective of the so far practical significance of the IHE profiles it appears to be of great importance, that the profiles are constantly checked against practical experiences and are continuously adapted.

The interconnection of medical networks in different healthcare institutions will be constantly increasing over the next few years, which will require concepts for securing medical data during transfer, since transmitting patient related data via potentially insecure public networks is considered a violation of data privacy. The aim of our work was to develop a model-based approach towards end-to-end security which is defined as continuous security from point of origin to point of destination in a communication process. We show that end-to-end security must be seen as a holistic security concept, which comprises the following three major parts: authentication and access control, transport security, as well as system security. For integration into existing security infrastructures abuse case models were used, which extend UML use cases, by elements necessary to describe abusive interactions. Abuse case models can be constructed for each part mentioned above, allowing for potential security risks in communication from point of origin to point of destination to be identified and counteractive measures to be directly derived from the abuse case models. The model-based approach is a guideline to continuous risk assessment and improvement of end-to-end security in medical networks. Validity and relevance to practice will be systematically evaluated using close-to-reality test networks as well as in production environments.

Objectives: In Austria, the general practitioner (GP) is the first point of contact for persons with health problems. Depending on the severity of the person's medical condition, a GP may refer her or him to a secondary care hospital consultant, who reports findings back to the GP in form of a paper-based discharge letter. Researchers report that paper-based communication of medical documents between different health care providers is insufficient in quality, error prone and too slow in many cases. Our aim was to develop and to realise a strategy for a stepwise replacement of the paper-based transmission of medical documents with a distributed, shared medical record., Methods: In the first step of a three-steps strategy for development of a consistent, comprehensive and secure regional health care network, an electronic communication of discharge letters and diagnostic results between existing information systems of different health care providers in Tyrol, Austria, has been established: in the form of cryptographically signed S/MIME e-mail messages and, additionally, via a secure web portal system. In two further steps, an extension of the system by a bi-directional communication and by improvements of the web portal system is planned, leading to a comprehensive electronic patient record for shared care., Results: After realisation of step 1, in October 2004, about 3500 electronic discharge letters were sent out from the Innsbruck University Hospital (IUH), which represents about 8% of the total number of discharge letters of the IUH. In addition, a lot of feedback was received and legal, organisational, financial and methodical difficulties were overcome., Discussion: The stepwise approach to replace paper-based with electronic communication in the first step was helpful, since knowledge has been gained and cooperations were formed. For the realisation of a distributed, shared medical record (steps 2 and 3), it will not be sufficient only to replace paper-based transmission of medical documents with electronic communication technologies, but in the further steps, organisational changes will become necessary. As well, legal ambiguities must be resolved before a distributed medical record for cooperative care, used by several institutions as well as by patients, could be established.