• Thomas Schabetsberger, Elske Ammenwerth, Stefan Andreatta, Gordon Gratl, Reinhold Haux, Georg Lechleitner, Klaus Schindelwig, Christian Stark, Raimund Vogl, Immanuel Wilhelmy, and Florian Wozak.
• University for Health Sciences, Medical Informatics and Technology (UMIT), Institute for Health Information System, Eduard Wallnöfer-Zentrum 1, A-6060 Hall i.T., Austria. thomas.schabetsberger@umit.at
• Int J Med Inform. 2006 Mar 1; 75 (3-4): 209-15.

ObjectivesIn 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.MethodsIn 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.ResultsAfter 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.DiscussionThe 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.

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