Long-term experience with setup and implementation of an IHE-based image management and distribution system in intersectoral clinical routine



Sharing of medical data is crucial for the proper treatment of patients as it could reduce the risk of duplicated medical tests and speed up the care process if all documents are readily available. Despite great technical progress, sharing patient data while maintaining full control over the process in an intersectoral (in Germany, this describes the different actors in the healthcare system consisting of clinic, ambulatory care, etc.) setting remains a particular challenge. This paper focuses on the successful implementation of a privacy compliant, standards-based image-management component of a personal electronic health record.


Over a 5-year period, a sharing system based on readily available IHE profiles constructed around XDS has been built. It was necessary to create interfaces for the existing hospital sub-systems to become part of the network. Specifically, the imaging workflow had to be adapted to allow for fast and easy access to DICOM images utilizing a flexible web-based image viewer. In addition to the standard XDS workflow, an Imaging Cache was established which combines the Imaging Document Source and Consumer to guarantee fast and streaming-based access to all images in the network observing the high security standards of the hospital network.


The authors of this paper have proven that it is possible to build a fast and reliable sharing system based on IHE profiles using most of the transactions of XDS-I with some adaptions to the clinical workflow. Primary hospital systems were enabled by building adapters to overcome lack of IHE compatibility. The established system embraces the existing security mechanisms in hospital networks while connecting patients and referring physicians from outside in a secure and convenient manner.


A state-of-the-art sharing system that is used in a productive clinical environment has been established and is ready to grow with more partners. The system is the basis for an elaborated interdisciplinary collaboration where data, and in particular images, can now be shared between medical professionals.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8


  1. 1.

    Arbeitsgemeinschaft Informationstechnologie der Deutschen Röntgengesellschaft (@GIT).

  2. 2.

    Akademie der Unfallchirurgie (AUC).

  3. 3.

    Netzwerk für Telekooperation in der Medizin (TKmed).

  4. 4.

    Bundesministerium für Bildung und Forschung (BMBF).


  1. 1.

    Internet Society (2018) Global internet maps. https://www.internetsociety.org/map/global-internet-report/. Accessed 03 Jan 2018

  2. 2.

    NEMA/MITA (2017) Standard Publications PS 3.1. Digital imaging and communications in medicine (DICOM), medical imaging and technology alliance (MITA), 1300 North 17th Street, Suite 900, Arlington, VA 22209, USA. http://www.dicomstandard.org/current/. Accessed 03 Jan 2018

  3. 3.

    Health Level Seven (HL7) Inc. Standard for electronic data exchange in all healthcare environments. http://www.hl7.org. Accessed 03 Jan 2018

  4. 4.

    Integrating the Healthcare Enterprise (IHE). https://www.ihe.net. Accessed 03 Jan 2018

  5. 5.

    Hussein R, Engelmann U, Schröter A, Meinzer HP (2004) Implementing a full-feature PACS solution in accordance with the IHE technical framework. Acad Radiol 11:439–447. https://doi.org/10.1016/S1076-6332(03)00821-3

    Article  PubMed  Google Scholar 

  6. 6.

    Teleradiologie-Projekt Rhein-Neckar-Dreieck. http://www.teleradiologie-rnd.de/. Accessed 03 Jan 2018

  7. 7.

    Engelmann U, Schröter A, Schweitzer T, Meinzer HP (2003) Teleradiologie per E-Mail und DICOM: Ein neues Konzept für das Schlaganfall-Netzwerk in Rheinland-Pfalz. Fortschr. Röntgenstr 175:S310

    Article  Google Scholar 

  8. 8.

    Weisser G, Engelmann U, Ruggiero S, Runa A, Schröter A, Baur S, Walz M (2007) Teleradiology applications with DICOM-e-mail. Euro Radiol 17(5):1331–1340. https://doi.org/10.1007/s00330-006-0450-8

    CAS  Article  Google Scholar 

  9. 9.

    Weisser G, Walz M, Ruggiero S, Kämmerer M, Schröter A, Runa A, Mildenberger P, Engelmann U (2006) Standardization of teleradiology using Dicom e-mail: recommendations of the German radiology society. Eur Radiol 16(3):753–758

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Engelmann U, Schütze B, Schröter A, Weisser G, Walz M, Kämmerer M, Mildenberger P (2005) DICOM-e-mail: the German minimal standard for teleradiology. In: Lemke HU, Inamura K, Doi K, Vannier MW, Farman AG (eds) Proceedings of the 19th international congress and exhibition computer assisted radiology and surgery CARS 2005. Elsevier, Amsterdam, pp 926–931

  11. 11.

    Engelmann U, Seidel B (2009) DIN 6868-159: a German standard for quality assurance in teleradiology. Int J CARS 4(Suppl 1):158–159

    Google Scholar 

  12. 12.

    Schwind F, Münch H, Schröter A, Meinzer HP, Engelmann U (2011) Advanced transfer statistics for acceptance and constancy testing of teleradiology networks. Int J CARS 6(Suppl 1):65–66

    Google Scholar 

  13. 13.

    Schwind F, Münch H, Schröter A, Engelmann U, Weisser G (2013) Ein Whitepaper zur Administration und Qualitätssicherung von DICOM E-Mail basierten Teleradiologie-Netzwerken. Duesberg F. (Hrsg.): e-Health, pp 196–199

  14. 14.

    Staemmler M, Walz M, Weisser G, Engelmann U, Weininger R, Ernstberger A, Sturm J (2012) Establishing end-to-end security in a nationwide network for telecooperation. In: Mantas J et al (eds) Quality of life through quality of information. Proceedings of MIE2012. IOS Press, Amsterdam, pp 512–516

  15. 15.

    Staemmler M, Walz M, Weisser G, Engelmann U, Luitjens KD, Schmucker U, Sturm J (2014) TKmed—Telekooperation für die einrichtungsübergreifende Versorgung. Duesberg F. (Hrsg.): e-Health, pp 217–220

  16. 16.

    Engelmann U, Münch H, Rimmler B, Schwind F, Staemmler M, Sturm J (2016) Tkmed Direkt: Spontaner Austausch von medizinischen Bilder und Dokumenten mit Kollegen, Zuweisern und Patienten. Duesberg F. (Hrsg.): e-Health. pp 84–87

  17. 17.

    Staemmler M, Rimmler B, Münch H, Engelmann U, Sturm U (2017) Ad hoc participation in professional tele-collaboration platforms. In: Hayn D, Schreier G (eds) Health informatics meets eHealth. https://doi.org/10.3233/978-1-61499-759-7-55

  18. 18.

    Engelmann U, Schwind F. Bildkommunikation in der Medizin: Vom PACS zum flächendeckenden E-Health-System. Müller-Mielitz S, Lux T (Hrsg.): E-Health-Ökonomie. https://doi.org/10.1007/978-3-658-10788-8

    Google Scholar 

  19. 19.

    Schwind F, Münch H, Schröter A, Weisser G, Meinzer HP, Engelmann U (2012) Using control messages for administrative tasks and constancy testing of DICOM e-mail based teleradiology networks. Int J CARS 7(Suppl 1):98–99

    Google Scholar 

  20. 20.

    Bergh B, Brandner A, Heiß J, Kutscha U, Merzweiler A, Pahontu R, Schreiweis B, Yüksekogul N, Bronsch T, Heinze O (2015) The role of integrating the healthcare enterprise (IHE) in telemedicine. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 58(10):1086–1093. https://doi.org/10.1007/s00103-015-2226-2

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    INFOPAT. https://www.infopat.eu. Accessed 03 Jan 2018

  22. 22.

    INFOPAT (2012) Abteilung MIS—Universitätsklinikum Heidelberg. INFOrmationstechnologie für die PATientenorientierte Gesundheitsversorgung in der Metropolregion Rhein-Neckar. https://mis-hd.eu/de/projekte/infopat/. Accessed 03 Jan 2018

  23. 23.

    BMBF. Federal ministry of education and research. https://www.bmbf.de

  24. 24.

    IHE-D (2013) IHE-D cookbook v1, pp 36–37. http://www.ihe-d.de/projekte/ihe-d-cookbook/. Accessed 03 Jan 2018

  25. 25.

    Brandner A, Schreiweis B, Aguduri LS, Bronsch T, Kunz A, Pensold P, Stein KE, Weiss N, Yüksekogul N, Bergh B, Heinze O (2016) The patient portal of the personal cross-enterprise electronic health record (PEHR) in the Rhine-Neckar-region. Stud Health Technol Inf 228:157–161. https://doi.org/10.3233/978-1-61499-678-1-157

    Article  Google Scholar 

  26. 26.

    Pensold P, Schneider G, Aguduri LS, Brandner A, Bronsch T, Schreiweis B, Stein KE, Weiss N, Yüksekogul N, Bergh B, Heinze O (2016) Implementing the patient portal of the PEHR in the metropolitan region Rhine-Neckar—experiences with liferay. Stud Health Technol Inf 228:105–109. https://doi.org/10.3233/978-1-61499-678-1-105

    Article  Google Scholar 

  27. 27.

    Yüksekogul N, Schreiweis B, Weiss N, Aguduri LS, Brandner A, Bronsch T, Pensold P, Stein KE, Helmer A, Bergh B, Heinze O (2016) Patient portal integration—a native IHE connector implementation for PEHR. Stud Health Technol Inf 228:172–176. https://doi.org/10.3233/978-1-61499-678-1-172

    Article  Google Scholar 

  28. 28.

    Ose D, Kunz A, Pohlmann S, Hofmann H, Qreini M, Krisam J, Uhlmann L, Jacke C, Winkler EC, Salize HJ, Szecsenyi J (2017) A personal electronic health record: study protocol of a feasibility study on implementation in a real-world health care setting. JMIR Res Protoc 6(3):e33. https://doi.org/10.2196/resprot.6314

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Baudendistel I, Winkler E, Kamradt M, Brophy S, Längst G, Eckrich F, Heinze O, Bergh B, Szecsenyi J, Ose D (2015) The patients’ active role in managing a personal electronic health record: a qualitative analysis. Support Care Cancer 23:2613–2621. https://doi.org/10.1007/s00520-015-2620-1

    Article  PubMed  Google Scholar 

  30. 30.

    Bozorgmehr K, Szecsenyi J, Ose D, Besier W, Mayer M, Krisam J, Jacke CO, Salize HJ, Brandner R, Schmitt S, Kiel M, Kamradt M, Freund T (2014) Practice network-based care management for patients with type 2 diabetes and multiple comorbidities (GEDIMAplus): study protocol for a randomized controlled trial. Trials 21(15):243. https://doi.org/10.1186/1745-6215-15-243

    Article  Google Scholar 

  31. 31.

    Baudendistel I, Winkler E, Kamradt M, Längst G, Eckrich F, Heinze O, Bergh B, Szecsenyi J, Ose D (2015) Personal electronic health records: understanding user requirements and needs in chronic cancer care. J Med Internet Res 17(5):e121. https://doi.org/10.2196/jmir.3884

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Projekt INFOPAT: GESIS Teilprojekt M1, Methodische Unterstützung des BMBF-Projekts “Metropolregion Rhein-Neckar, Raum für Gesundheit” (INFOPAT). https://www.gesis.org/forschung/drittmittelprojekte/archiv/infopat/. Accessed 30 April 2018

  33. 33.

    Bresser L, Köhler S, Schwaab C (2014) The development of an application for data privacy by applying an audit repository based on IHE ATNA. Stud Health Technol Inf 198:219–225. https://doi.org/10.3233/978-1-61499-397-1-219

    Article  Google Scholar 

  34. 34.

    Weiss N, Aguduri LS, Yüksekogul N, Schreiweis B, Brandner A, Bronsch T, Pensold P, Stein KE, Bergh B, Heinze O (2016) Implementing PEHR: design and integration of a consent creator service. Stud Health Technol Inf 228:167–171. https://doi.org/10.3233/978-1-61499-678-1-167

    Article  Google Scholar 

  35. 35.

    IHE (2017) IHE IT infrastructure technical framework, volume 2a ITI TF-2a

  36. 36.

    IHE (2017) IHE IT infrastructure technical framework, volume 2b ITI TF-2b

  37. 37.

    IHE. Wiki—cross-enterprise document sharing, actors and transactions. https://wiki.ihe.net/index.php/Cross-Enterprise_Document_Sharing. Accessed 30 April 2018

  38. 38.

    IHE (2017) IHE radiology (RAD) technical framework, volume 3 IHE RAD TF-3

  39. 39.

    IHE. Wiki—cross-enterprise document sharing for imaging, actors and transactions. https://wiki.ihe.net/index.php/Cross-enterprise_Document_Sharing_for_Imaging. Accessed 30 April 2018

  40. 40.

    IHE (2017) IHE radiology (RAD) technical framework, volume 2 IHE RAD TF-2

  41. 41.

    BMBF. Metropolregion Rhein-Neckar—Raum für Gesundheit. https://www.gesundheitsforschung-bmbf.de/de/teilprojekte-m1-p0-p2-p3-p4-p5-p7-p8-p9-4178.php. Accessed 03 Jan 2018

Download references


The INFOPAT project and especially the corresponding development sub-project P2 was co-funded by the German Federal Ministry of Education and Research (BMBF, funding code 01KQ1003B) [41]. We would like to thank all other project partners working with us during this project.

Author information



Corresponding author

Correspondence to F. Schwind.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Human and animals rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Schwind, F., Münch, H., Schröter, A. et al. Long-term experience with setup and implementation of an IHE-based image management and distribution system in intersectoral clinical routine. Int J CARS 13, 1727–1739 (2018). https://doi.org/10.1007/s11548-018-1819-2

Download citation


  • IHE
  • XDS
  • XDS-I
  • PACS
  • Image management
  • Data management
  • Interoperability