Modular Architecture of Value-Added Applications for German Healthcare Telematics

Sebastian Dünnebeil, Ali Sunyaev, Jan Marco Leimeister, Helmut Krcmar

Business and Information Systems Engineering (2013)5(1)

Appendix (available online at

Appendix 1

Implementation Details and Limitations

As a basis for the technical evaluation of VAA of TI we used a connector from Koco Connector (Release 3.0.0) (gematik, 2009b) and a card reader from SCM (Release 2.8.0) (gematik, 2009c). In addition, we had a set of test cards of generation 1 (G1) provided by gematik. Besides Smart Media Cards, health professional cards(HPC)and electronic health cards (eHC) were employed. Only the decentralized functions of the connector could be used, as at the time there was no link between connector and central TI. The central services of the application were not available as VAA of TI as central components of TI do not yet exist. A migration to a central service is aimed for. As primary systems we made use of AIS DocConcept and DocStar (KBV, 2011) to imbed the application into a realistic environment of ambulatory care. The source system for the eReferral was the AIS DocConcept, the chosen target system AIS Doc.Star. Access to master data, diagnoses, medication, results, and laboratory findings was implemented. Databank access was handled via OLE DB driver; the interface was implemented in C# and provided in the form of an XML web service. Logical Observation Identifiers Names and Codes (LOINC) were used to clearly identify the kind of medical input. For the prescription signature the connector interface SignDocument with the signature policy for VAA “GeneralDetached Signature” is used (gematik, 2009b). The document is shown in the Extended Trusted Viewer (XTV) of the connector, before the signature can be created. As the directory service of gematik is not yet available, the certificates of the test cards were stored in the target system. The use of eHC and HPC for codifications, as described in gematik (2009d) for applications of TI conforming to § 291a of SGB5, cannot yet fully be realized. Deciphering of the eReferral by the patient was not possible, as the specification of the connector explicitly does not allow this without an HBA (gematik, 2009b). A component for the patient to decipher data, as envisaged in the architecture specification under Patient@Home (Fraunhofer, 2005), has not yet been specified. Services of local components (connector and card reader) are used to hybridlyencrypt the eReferral. The connection between local and central VAA is not yet constructed through a Virtual Private Network (VPN) tunnel, just a server certificate is used.

Appendix 2

Functional Requirements of eReferral

FR 1 / All physicians of the practice network should be given the option to offer an appointment reservation service via a common IT platform.
FR 2 / Patients and medical staff should have the option via a common IT platform to find and reserve available appointments and treatment sessions in their neighborhood without having to contact various physicians by telephone.
FR 3 / General practitioners should have the option to copy data from their local primary system into an electronic referral form and to send this in encrypted form to a specialist.
FR 4 / Reserving of specialist appointments should be restricted to patients and medical staff only on the basis of a valid referral to a specialist.
FR 5 / The reservation of multiple specialist appointments using a single referral form must be prevented.
FR 6 / Patients without internet connection of with cognitive or physical limitations must be able to use the application without any disadvantages.
FR 7 / Patients must be allowed to choose a medical specialist freely.
FR 8 / The physicians’ network should have the option to store medical and administrative data from the referral centrally in order to carry out control activities and quality assurance measures.

Appendix 3

Process “Referral to Specialist”

Fig. A1 Network data selection and appointment scheduling

The process shall illustrate the treatment relevant communication of medical, administrative, and appointment related data from patient via general practitioner to specialist and health insurance. Participants are to have access,according toAugustin (1990), only to those files which are necessary for them to provide their services according to legal and subject-specific points. Communication is to be simplified in order to achieve a process that describes and supports the current procedures in the institutions with the best technical means possible. The focus is not on technical aspects, as is the case in existing specifications of gematik, but gives priority to functional considerations. Merely envisaged but scarcely formulated conceptions, such as the patients’ box (gematik, 2009a), an interface for the exchange of data between patient and general practitioner, give no evidence as to the context of the information exchange. A more detailed description of a concrete implementation of the process is the form for the patient’s self-anamnesis . This can be filled in when making an appointment if the patient sees the necessity of medical care. The form can collect patient information on the web site of the practice net while arranging for an appointment, safely transmit it to the addressed institution and translate it into the specific language of the physician (1). After revision by the general practitioner and his signature, the patient information becomes a verified medical document (Dünnebeil et al., 2009). The referral, describing the communication of information to a medical specialist in a specialized surgery or a hospital (2), contains both administrative data, such as the referral form, which entitles to a specialist’s treatment and is used for invoicing the health insurance, and also a component with medical data. These data elements are to be combined with an appointment component, outlining the agreement of a consultation between patient and specialist, and is to be used for the authorization of later health care providers to gain access to the patient’s data (3) (Dünnebeil et al., 2011). For invoicing, medical data should be removed from the referral (4) in order to communicate only the accounting data relevant for the cost bearer (5). The return information from the specialist to the responsible general practitioner can be handled by means of the electronic doctor’s letter (6). Thus medical data flow back to the general practitioner, and with each step of this process the substantial quality improves.

References (Appendix)

Augustin S (1990) Information als Wettbewerbsfaktor: Informationslogistik. Verlag TÜV Rheinland 1990

Dünnebeil S, Mauro C, Sunyaev A, Leimeister JM, Krcmar H (2009) Integration of patient health portals into the German healthcare telematics infrastructure. Proc 15th Americasconference on information systems (AMCIS), San Francisco, Paper 754