Information Systems for Specific Health Care and Research Settings

Abstract

Health care in different life situations is provided in various health care settings. Consequently, the information systems of different health care settings show specific characteristics both from a technological and a management perspective.

Information systems in hospitals have to address the information needs of many clinical and administrative areas and groups of persons. Hospital information systems must therefore support a large number of functions and integrate a comparably large number of application components. Integrity and integration are thus especially crucial topics. Overall, systematic information management is essential in hospitals, being the most complex institutional health care setting.

Information systems in nursing homes are typically less complex, as the number of areas and persons is smaller. Consequently, the number of application components is lower than in hospitals. Information systems in ambulatory nursing organizations and medical offices are even less complex and may comprise an even smaller number of application systems. Nevertheless, systematic management of the specific information systems is still needed at least to some extent in order to respond to specific requirements in these health care settings.

Information systems in medical research facilities support dedicated functions such as research management or the planning and executing of studies. They typically comprise numerous application components and also have to respond to the requirement of cross-institutional or interprofessional research collaboration.

Information systems in personal environments may typically support wellness, prevention, treatment, or rehabilitation and may be either part of institutional health information systems or be realized as a separate information system in a personal environment.

6.1 Introduction

In Chaps. 3 and 4, we introduced health information systems and two perspectives when dealing with them: the technological perspective and the management perspective. Using the technological perspective, we describe the architecture and integration of an information system. Using the management perspective, we describe the strategic, tactical, and operational management of an information system.

In this chapter, we will now refer to these perspectives with respect to specific health care settings. Please recall Chap. 1 where life situations and their relative share of health care were introduced. The following institutional health care settings were mentioned in particular:

• In hospitals, patients with acute and chronic diseases or in an emergency situation receive inpatient and, partially, outpatient treatment.

• In nursing homes, persons receive care.

• In medical offices, patients with acute and chronic diseases receive outpatient treatment.

• Ambulatory nursing organizations take care of persons in their homes.

Each health care setting thus has a specific role in providing health care and is related to specific life situations. This specific role corresponds to specific structures, processes, and stakeholder groups in these different health care settings. Not surprisingly, the information systems of these health care settings also show typical differences both from a technological and from a management perspective that we want to explore further in this chapter.

Besides discussing information systems in these institutional health care settings, we will also address information systems for medical research facilities as well as transinstitutional information systems in regions or in states. We will also discuss how personal environments such as homes can be considered for health care (Fig. 6.1).

Fig. 6.1

Health information systems constitute an essential part of providing good health care. Patient with shoulder pain trains at home with an autonomous rehabilitation system

For most of these health care settings, you will first be introduced to their characteristics, such as their activities, areas, and persons. Then we will describe their specific technological and management perspectives, building on Chaps. 3 and 4.

As mentioned in Chap. 1, health care organizations can vary from country to country. Therefore, the characteristics described here, as well as their technological and management perspectives, may also differ to some extent from country to country.

Please also recall the definitions of “information system” and “health information system” in Chap. 2 with respect to specific health care settings. Let us take hospitals as an example of such health care settings: Hospital information systems are the socio-technical subsystem of hospitals, which comprise all data, information, and knowledge processing as well as the associated human or technical actors in their respective data, information, and knowledge processing roles. The same holds accordingly for other health care settings mentioned in this chapter.

After reading this chapter, you should be able to

• describe characteristics of different health care settings,

• explain the resulting implications for the technologies used and the management of information systems in these health care settings, and

• explain the differences of specific health information systems and their management.

Please note that the terms highlighted in italics are terms from the glossary or represent functions or application system types.

6.2 Information Systems in Hospitals

6.2.1 Characteristics of Hospitals

Hospitals are settings where patients with acute and chronic diseases or in an emergency situation receive inpatient and, partially, outpatient treatment.

Areas of hospitals to be considered by hospital information systems are wards, outpatient units, service units (e.g., diagnostic units such as laboratory and radiology departments, therapeutic units such as the operation room, and other units such as pharmacy, patient records archive, library, blood bank), hospital administration areas (e.g., patient administration department, department of quality management, financial and controlling department, department of facility management, information management department, general administration department, human resources department), offices, and writing services for (clinical) report writing. In addition, there are the management areas, such as hospital management, management of clinical and non-clinical departments, administration management, and nursing management. These areas are related to patient care. They could be broken down further. For university medical centers, additional areas for research and education must be added to the above list.

The most important persons in a hospital are, obviously, patients. Important groups of persons working in a hospital are physicians, nurses, administrative staff, technical staff, medical informaticians, and health information management staff. Within each group of persons, different needs and demands on the hospital information system may exist depending on the role, tasks, and responsibilities. Ward physicians, for example, require different information than physicians working in service units or senior physicians. Patients sometimes need similar information as physicians but in a different form.

6.2.2 Technological Perspective

Hospitals can be considered as quite complex institutional health care settings. Therefore, nearly all functions mentioned in Chap. 3, together with their data to be processed, have to be considered, as well as many of the application components, nearly all of which can be part of a hospital information system. The examples in Chap. 3 were often taken from hospitals because of this fact. Consequently, integrity and integration are especially crucial when managing hospital information systems.

6.2.3 Management Perspective

As hospitals are such complex entities, there are many different stakeholder groups with sometimes conflicting requirements regarding the hospital’s information system. These stakeholder groups include the various professional groups (physicians, nurses, administrators, researchers, teachers, etc.). In this situation, systematic information management and a carefully planned step-by-step approach of shaping the information system are essential. Thus, all tasks and methods presented in Chap. 4 have to be considered by the management of the information system. Due to the same reason, most examples in Chap. 4 were taken from hospitals.

6.3 Information Systems in Nursing Homes

6.3.1 Characteristics of Nursing Homes

Nursing homes are organizations primarily related to the care of persons with physical and mental functional deficits. These are often, but not exclusively, senior citizens at an advanced age. They are usually called residents.

The most important working areas in nursing homes are the wards and the residents’ rooms, the administration areas, and the management areas (especially nursing management). Depending on their specialty, nursing homes may have dedicated areas for therapeutic services. Nursing homes can be of very different size, ranging from a few to hundreds of beds.

The most important persons in a nursing home are, obviously, the nursing home residents. In addition, the visitors are also of great importance and special amenities and services are provided for them as well. Important groups of persons working in a nursing home are nurses as well as administrative and management staff.

6.3.2 Technological Perspective

In nursing homes, the functions to be performed are mainly those of nurses and administrative staff. The typical application component is the nursing management and documentation system (NMDS) that supports major functions such as patient administration, decision-making, planning, organization of patient treatment, and coding. In the event that external physicians or other specialists are involved in patient care, they may also document their findings in the NMDS. Otherwise, they may use their own application system for documentation (such as the application system of the general practitioner (GP)). In the latter case in particular, but also in order to be able to receive prescriptions and findings from specialists and laboratories, for example, communication links from the NMDS to application systems outside the nursing home are required. The interoperability standards and integration technologies from Chap. 3 can be used for this purpose. A prerequisite, however, is the physical integration discussed in Sect. 3.10.2 based on a secure data transmission connection at the physical tool layer.

6.3.3 Management Perspective

Management of information systems in nursing homes is typically reduced. Often, senior nursing managers will be responsible for organizing management of information systems. Sometimes, they may be supported by the vendor of the NMDS which delivers and maintains the software and sometimes the hardware.

The aforementioned requirements of the technology, particularly with regard to the necessary external communication, also lead to special challenges in the area of data security. In particular, if the nursing home, unlike a hospital, does not have its own professional information managers, the management of the home must take strict care to ensure that the tasks of professional and systematic information management are nevertheless covered. It is a good idea to outsource the corresponding services to specialized external companies. But even such a solution does not relieve the home management of its responsibility for the information system.

6.4 Information Systems in Medical Offices

6.4.1 Characteristics of Medical Offices

Medical offices are settings where patients with acute and chronic diseases receive outpatient treatment.

The most important working areas in medical offices are the examination and treatment rooms. Further areas for patients that we must consider are waiting areas with, for example, waiting rooms. All this is similar to outpatient units in hospitals. In addition, areas for administrative purposes, for example, patient management, billing, and telephone services, can often be found in medical offices. Depending on their specialty, medical offices (in particular specialist offices) may have additional areas for diagnostic or therapeutic services.

As in hospitals, the most important persons in medical offices are patients. The three groups of persons usually working in medical offices are physicians, other health care professionals (e.g., nurses, laboratory staff, psychologists, physiotherapists), and administrative staff. Whereas hundreds or thousands of health care professionals work in hospitals, the number of persons working in medical offices is much lower, often less than 10. Information systems for medical offices have to support these persons’ needs. Obviously, the complexity of information systems of medical offices is less than the one of the hospitals.

6.4.2 Technological Perspective

In medical offices, the functions to be performed are mainly those of health care professionals and of administrative staff with regard to patient care and administration. As in other settings, application systems are needed which support functions such as patient administration, decision-making, planning, organization of patient treatment, and coding. Typically, a patient administration system and a medical documentation and management systems (MDMS), both based on software from a single vendor, are combined into a single application system. The result is similar to the clinical information system (CIS) and electronic health record system (EHRS) discussed in Sect. 3.4.15. In the case of specialist medical offices with additional areas for diagnostic or therapeutic services, additional application systems for these functions can be found, for example, a radiology information system (RIS) together with a picture archiving and communication system (PACS) or laboratory information system (LIS). If so, integration of these application systems in the office is needed as discussed in Chap. 3.

Medical offices exchange a wide range of information with nursing homes, laboratories, hospitals, specialists, and other care facilities. Therefore, secure interfaces for external communication must also be provided for its application systems (Chap. 3).

6.4.3 Management Perspective

Medical offices are sometimes independent “small enterprises”. Other times, they are part of a larger health care facility. Medical offices are even smaller than nursing homes and can hardly have their own information management staff. If the medical offices are independent enterprises, however, they still need to take responsibility for the information management. Ensuring data security in particular must not be neglected under any circumstances. The owner or the management of the medical office will then be responsible for the management of the information system, sometimes supported by consulting companies, which also deliver and maintain hardware and application software products for application systems in these offices. If the medical offices are part of a larger health care facility, information management is usually handled by the IT departments of these facilities.

6.5 Information Systems in Ambulatory Nursing Organizations

6.5.1 Characteristics of Ambulatory Nursing Organization

Ambulatory nursing organizations are primarily related to the care of persons with physical and mental functional deficits living at home. These are often, but not exclusively, senior citizens at an advanced age that are visited regularly by ambulatory nurses.

The most important working areas therefore are the patients’ homes as well as an administrative office area where the visits are coordinated. The most important persons working for ambulatory nursing organizations are nurses, supported by administrative and management staff. Ambulatory nursing organizations can be of very different size, from a few to hundreds of nurses.

6.5.2 Technological Perspective

Ambulatory nursing organizations need support for the overall coordination and organization of the visits at the patients’ homes as well as for nursing management and documentation, done mostly at the patients’ bedside, and for administration and billing. The respective functions are compiled in Table 3.3.

Ambulatory nursing organization may use an NMDS that also offers special features for organization and coordination of visits at patients’ home. At the physical tool layer, mobile tools are often used to facilitate information processing at the patients’ homes when using the NMDS.

6.5.3 Management Perspective

As for medical offices, ambulatory nursing organizations may be small enterprises or part of larger organizations. Management of information systems in ambulatory nursing organizations depends on the size of the organization here as well. The owner or the management of the organization will then be responsible for the management of the information system. Sometimes, they may be supported by the vendor of the NMDS which delivers and maintains the software and sometimes the hardware as well.

6.6 Information Systems in Medical Research Facilities

6.6.1 Characteristics of Medical Research Facilities

Medical research facilities exist in a variety of shapes and with different characteristics. Medical research is conducted at university medical centers, for example, in specialized working groups, institutes, or sub-units, but may also be conducted in universities, associated institutes, or industrial facilities, for example, in the pharmaceutical industry. Medical research usually is interdisciplinary and involves heterogeneous data on various entity types, for example, “clinical trial,” “finding,” or “classified diagnoses” (Sect. 3.2.3.4). Especially in academic centers, efficient research and education must be supported. The objective of clinical research is the generalization of findings and experiences to gain new knowledge. Data documented during the patient treatment process may be reused for retrospective analysis to find evidence for generalization and to generate hypotheses for new studies.

6.6.2 Technological Perspective

Research facilities are very different from patient care facilities in terms of the functions to be performed and also in terms of the application systems to be used. For this reason, we will discuss both the specific functions and the application systems in more detail below. The following specific information processing functions need to be supported (Fig. 6.2).

Fig. 6.2

Extract of the domain layer of the 3LGM²-based reference model describing the function research and education, its subfunctions and interpreted and updated entity types

Experiments and clinical trials are important for the progress in medicine because they update biomedical and health knowledge. Scientific staff must be supported in planning, executing, and analyzing studies and experiments. Planning and execution must conform to legal requirements. For example, patients have to be informed of opportunities and risks before they can consent to taking part in a clinical trial. Data documentation needs to fulfill the de facto standard of minimal requirements for managing research data, the FAIR criteria for research data management: findable, accessible, interoperable, and reusable. Significant progress in research, for example, in generating new hypotheses for later prospective studies or by uncovering new pathomechanisms or pathways associated with diseases, is also achieved through retrospective analysis of large amounts of heterogeneous data. These data-driven scientific approaches must also be supported by research facilities.

Finally, for research data, processes of pseudonymization and/or anonymization must be supported wherever necessary in order to conform to legal requirements.

Scientific staff needs to prepare publications and presentations. Therefore, central collections of both the facility’s relevant publications and other literature need to be made available to them using a standardized interface. Scientific staff needs access to research-relevant information and general medical knowledge.

Medical casuistic and treatment data must be made available for training and education in medical professions. Furthermore, the organization and execution of teaching and exams, for example, through e-learning tools and tools for taking electronic exams, must also be supported.

Research management is executed in all of the hospital’s organizational units which decide on planning, monitoring, and directing research activities. This includes the documentation of research activities as well as the management of third-party funds and the management of scientific sub- or service units within facilities.

To implement the above-mentioned functions, numerous different application components usually exist. Frequently, medical research facilities run multiple decentralized database systems or repositories for specific research purposes, projects, or trials. Clinician scientists often call these “cohort” databases, reflecting the longitudinal or cross-sectional nature of data capture. Dedicated research data management offices support researchers in creating such data repositories or registries in accordance with FAIR criteria by consulting them in terms of how to plan, conduct, and document research projects and by supporting them in selecting standards for structuring, representing, and saving their data along with appropriate metadata, thus aiming for a certain degree of interoperability and reusability.

For clinical trials which have to fulfill very high standards with regard to data quality, data monitoring, versioning, etc., dedicated electronic data capture (EDC) systems are used. These offer customizable data entry forms and various export formats, most notably using CDISC standards (Sect. 3.7.2.11).

Data from clinical application systems which are provisioned for reuse in research are frequently stored in data warehouse systems (DWS), data lakes (repositories for raw, often unstructured data), or open platforms (Fig. 6.3). If the facility does not run an open platform, all of the above require some sort of export (e.g., as Health Level 7 (HL7) messages, HL7 FHIR) or extraction process from clinical application systems. While data lakes incorporate raw data such as files, blobs, or genomic sequences, DWS, as invariant systems for research, require an extract, transform, load (ETL) process, during which quality checks, and mapping to terminologies may be performed. Open platforms, in contrast, provide care-level, longitudinal patient-related data of the highest quality and semantic definition, so that clinical or research applications as well as registries can be built upon them. For research purposes, a research copy of the EHR with pseudonyms may be used.

Fig. 6.3

Logical tool layer: application components supporting the reuse of clinical data during “planning, execution and analyzing studies and experiments”

With rising needs of cross-institutional or international research collaboration, data sharing, and integration, many medical research facilities establish central units called data integration centers (DIC). They integrate data and run all systems that enable cross-institutional querying and data exchange, while at the same time taking care of use-and-access processes and their documentation, data protection and safety, consent management, and all activities related to data integration and semantic enhancement (e.g., terminology binding).

Medical research requires a great deal of creativity, and the application and database systems used must be flexibly adaptable to new research questions being investigated. Therefore, it is necessary to enforce the use of open standards for data representation, so that the data are reusable in future projects and in different contexts. Likewise, open interfaces and standardized query languages are necessary for data access. This facilitates rapid and flexible software development for research.

Systems for research often demand huge storage capacity as well as adequate network bandwidth, particularly in the disciplines concerned with omics (e.g., in metabolomics) or imaging data. Research organizations must anticipate future storage needs and provide adequate physical storage systems as well as highly performant computing infrastructures for extensive analyses of large and heterogeneous datasets. For this purpose, facilities frequently run their own high-performance computing clusters, including special GPU (graphics processing unit) systems. Employing cloud solutions may also be useful to share computing capacities with other research facilities.

Medical research is also dependent on international cooperation, which requires even more flexible options for digital communication beyond the boundaries of the facility than is necessary for health care facilities. When research facilities are part of a health care facility, the physical data processing systems of the research facility are therefore connected in a separate part of the communication network that is strictly separated from the communication network of the health care facility.

6.6.3 Management Perspective

Information systems in medical research facilities demand dedicated and specialized management for optimal support of research endeavors. To fulfill FAIR criteria and in particular to enable data reuse and sharing within and across facilities, it is crucial to avoid home-made research infrastructures (e.g., using spreadsheets or proprietary databases) which are not or only partly interoperable with other systems. From a management perspective, it is crucial to define and enforce rules, processes, and standards for representing, storing, and sharing research data. To achieve this, dedicated research data management units can provide consultation and support for researchers, at the same time supervising a coherent management strategy. If they exist, these units may work closely together with DICs.

Strategic planning and establishing a strategic information management plan is particularly challenging in research institutions for two reasons. Firstly, it is difficult to foresee which research questions will have to be addressed in 5 years’ time. As a result, the application systems required for this purpose can also be predicted less well than in health care facilities. It is therefore necessary to plan primarily for generic tools and also software development groups in order to be able to adapt quickly to new research questions. Secondly, research is often funded on a project basis. Thus, it is often only known at fairly short notice what funding is available for the procurement of software and hardware; for the long-term maintenance and servicing of components, the necessary funds can often only be made available on an ad hoc basis. Consequently, a strategic information management plan will tend to provide a broad framework for the development of the research institution’s information system and focus on infrastructure (Sect. 2.11).

6.7 Information Systems in Other Health care Settings

In addition to the institutional health care settings already mentioned, there are a number of other institutions involved in health care services for people. These include:

• pharmacies,

• medical supply stores,

• therapeutic offices,

• inpatient and outpatient rehabilitation facilities,

• hospices,

• wellness facilities, and

• sports centers and leisure parks.

6.7.1 Characteristics of Other Health care Settings

6.7.1.1 Pharmacies

Pharmacies are settings where persons with acute or chronic diseases or for preventive purposes can obtain prescription-only or non-prescription medications as well as medical aids.

A pharmacy usually consists of three areas. The free-dial area refers to the sales area in front of the counter where non-pharmacy products are offered, such as band-aids, toothpaste, and teas. The area behind the counter, which is clearly visible to all customers, is called the sight-selection area. Here, a person will find pharmacy-only products that can be purchased without a prescription, such as light pain analgesics, cough syrups, or nasal spray. In the last area, the pharmacy warehouse, which is usually structurally separated from the sales area, prescription-only medications are stocked in special shelving systems and pharmacy lockers.

Many different professional groups are employed in pharmacies. The most important people working in pharmacies are pharmacists. They are the experts on medicines and are responsible for, among other things, the production and dispensing of medicines and advising patients. Every pharmacy must have at least one pharmacist on site at all times. In addition, there are a number of pharmaceutical personnel, such as pharmaceutical technical assistants, pharmacist assistants, and pharmaceutical assistants. However, non-pharmaceutical personnel also operate in pharmacies. These include pharmaceutical commercial assistants, pharmacy assistants, and skilled pharmacy workers.

6.7.1.2 Therapeutic Offices

There is a variety of different therapeutic offices that provide (therapeutic) treatment for people in the outpatient sector. These include offices for physical therapy, physiotherapy, occupational therapy, speech therapy, and massage therapy. In addition to the relief of physical complaints, however, there are also therapeutic offices for relieving mental complaints, such as psychotherapists or learning therapists.

Therapeutic offices, similar to medical practices, consist of a waiting area, a registration area with a reception desk, and one or more treatment rooms. The equipment of the individual treatment rooms depends on the therapeutic measures to be performed. Depending on the range of services provided by a facility, there may also be additional areas for specific therapeutic services. In physiotherapy practices, for example, it is not uncommon to find individual equipment areas for performing physiotherapy exercises.

Alongside patients, therapists are the most important professional group in therapeutic practices. Depending on the specialization of a therapeutic office, these include masseurs, physiotherapists, occupational therapists, or respiratory, speech, and voice teachers. The tasks to be performed vary considerably depending on the professions, but usually include both advanced diagnostics and therapy.

Quite often, medical assistants also work in therapeutic practices. They take on administrative and supporting activities.

6.7.1.3 Inpatient and Outpatient Rehabilitation Facilities

There are both outpatient and inpatient rehabilitation facilities of all sizes. Rehabilitation facilities are settings in which patients with a health condition are enabled “to remain in or return to their home or community, live independently, and participate in education, the labor market and civic life” [1]. For this purpose, rehabilitation facilities often focus on a specific discipline. For example, there are rehabilitation centers specialized in cardiological, neurological, or orthopedic rehabilitation.

Inpatient rehabilitation facilities, also called rehabilitation centers, are comparable to hospitals. Thus, there are also different wards and service areas which must be supported by an information system: patient rooms, community areas, treatment areas for individual and group therapy, administrative areas (e.g., patient administration department, financial and controlling department), and also a kitchen/canteen.

Outpatient rehabilitation centers are comparable to therapeutic offices, only that they are larger and usually offer a wider range of functions.

The most important people in rehabilitation facilities are the patients. Among the most important employees are the medical staff as well as various therapists (e.g., occupational therapists, speech therapists, and physiotherapists), nurses, and social workers. Alongside the medical-therapeutic staff, there are also a large number of employees in administrative areas, for example, typists, therapy planners, and receptionists. On top of this, there are various service employees, such as housekeepers and kitchen staff. The number of employees per facility strongly depends on the size and scope of the services provided.

6.7.1.4 Hospices

Hospices focus on the palliative care of critically ill patients and of persons passing away. Apart from relieving pain and enhancing the individual’s quality of life in their final phase of life, the tasks also include providing bereavement services for relatives. In addition to inpatient hospices, there also are outpatient hospice services that provide support for patients and relatives in their own homes or in an inpatient care facility.

Inpatient hospices are relatively small (8–16 beds) and consist of areas similar to inpatient care facilities. Alongside the patients’ rooms, hospices also have a reception area, administration, community rooms, guest rooms for relatives, staff rooms, and a kitchen.

Hospice care is provided by an interdisciplinary team. Alongside nursing staff with an additional palliative qualification (palliative care nurse), chaplains, psychologists, and social workers, hospice volunteers with training as assistant dying companions are also among the most important employees of hospices. There are also administrative staff and housekeepers. The number of nursing staff in a hospice depends on the number of beds available. In Germany, there is a care contract for inpatient hospice care that contains corresponding indications. Hospices, like inpatient nursing homes, do not have their own medical staff. Medical care is provided by physicians from general practices (primary care physicians) or from attached hospitals.

6.7.1.5 Wellness Facilities

Especially in the context of tertiary prevention, certain facilities play a role that one would not necessarily think of first in the context of a health care setting. For example, various wellness activities to increase well-being and relaxation, such as massages, can be performed in specific wellness centers, wellness, and cosmetic studios, but also in hotels specialized in this field. The main working areas in wellness facilities are the treatment rooms and, depending on the range of services, other additional areas for specific therapeutic services. In addition, there are reception or registration areas for administrative purposes and, in some facilities, also waiting rooms.

Besides the customer, or patient, the therapeutic staff, such as masseurs, physiotherapists, or sports therapists, are among the most important people of wellness facilities. The list of employees is completed by administrative staff. The number of employees depends on the size of the facility. In small wellness and cosmetic studios, there are often less than 10 people working there.

6.7.1.6 Sports Centers and Leisure Parks

Tertiary prevention may also coincide with rehabilitation. Sometimes, fitness activities can be performed not only in certified rehabilitation facilities but also in regular sports studios and sports parks. Furthermore, activities for primary prevention may be carried out in sports facilities.

Conventional fitness studios consist of various functional areas. The cardiovascular area is particularly suitable for improving general fitness and thus preventing diseases promoted by a lack of physical activity, such as high blood pressure and diabetes. Functional fitness areas with, for example, medicine balls and kettle bells as well as free weight areas are used for strengthening. Targeted strengthening of the shoulder, back, and neck muscles, for example, can reduce the risk of musculoskeletal disorders of the shoulder and back.

Customers, or members of a sports center, are one of the most important groups of people at sports centers and leisure parks. In addition, there are various service employees who are responsible for advising customers on site, assisting members at the reception desk, and offering sales services. Various specialized (fitness) trainers are responsible for training support and advice. The number of employees depends to a great extent on the size of a facility.

6.7.2 Technological Perspective

It is already clear from the basic characteristics described above that there are considerable differences in the functions to be performed depending on the facility or setting. In therapeutic practices and rehabilitation facilities, as in doctors’ practices and hospitals, the focus is on the medical or therapeutic treatment of people. The function of pharmacies, on the other hand, is to supply people with medicines and medical aids. For this purpose, it is necessary to produce, store, and test drugs, as well as to dispense these drugs to the patients and inform them about the intake, storage, and risks of a drug (advice).

Consequently, these diverse information processing functions also result in different requirements with regard to the application components that are usually used. While application components for prescription and medication management as well as specific pharmacy resource planning systems are used in a pharmacy, therapeutic practices such as medical practices have patient administration systems for admitting and registering patients, MDMS for documenting the therapeutic measures performed, and patient administration systems for billing purposes. Even if wellness facilities and sports facilities do not focus on a person as a patient, they nevertheless also have application components for scheduling, documenting the services performed, and billing.

6.7.3 Management Perspective

Due to the considerable differences in the functions to be performed in the various facilities or settings, the way in which management of information systems is organized also differs. The more complex the functions are, and the more persons are involved, the more management of information systems will be organized in a dedicated way as in hospitals. In the case of smaller settings and/or limited information processing functions, management of information systems might be assigned as an additional task to the management in these settings. As in medical offices, these persons might be supported by consulting companies, which may also deliver and maintain hardware and application software products for application components.

6.8 Information Systems in Personal Environments

6.8.1 Characteristics of Personal Environments as Health care Settings

Probably, the most important personal environment for persons are their homes. As personal environments, we may also regard workplaces and transport vehicles such as cars. As mentioned in Chap. 1, we primarily associate personal environments with our regular daily lives. Personal environments, however, may also be related to health care. Thus, besides supporting primary prevention and wellness for healthy people, personal environments may also support diagnostic and therapeutic activities, rehabilitation, or secondary and tertiary prevention (i.e., to reduce or soften the impact of a disease that has already occurred). Health care activities in our personal environments are often denoted with terms starting with “tele” or “home,” for example, telecare, telemedicine, telerehabilitation, or home care.

6.8.2 Technological Perspective

In the case of tele-activities supporting diagnostics or rehabilitation, these activities are often assigned to health care facilities such as hospitals, medical offices, or ambulatory nursing organizations. In this case, the functions and application systems can be regarded as part of the information systems of these settings. However, the information processing activities of these settings do not end within the walls of these settings but take place in a personal environment. Therefore, technical complexity is higher and efforts with regard to data privacy and security are more demanding, as informational self-determination is a very sensitive matter.

In the case of wellness and of primary prevention, the situation is different. Here, persons install application systems as introduced in Chap. 3 on their own and use these in their personal environments.

6.8.3 Management Perspective

In the case of activities which can be assigned to health care settings such as hospitals, medical offices, or ambulatory nursing organizations, management of information systems is primarily done by these settings. In other activities, for example those related to wellness or primary prevention, the persons themselves are responsible. We would hardly call this management of information systems although it would technically be correct.

6.9 Information Systems in States and Regions

6.9.1 Characteristics of States and Regions as Health care Settings

In the Universal Declaration of Human Rights of 1948, the right to health is found as part of the right of all people to an adequate standard of living. In the International Covenant on Economic, Social and Cultural Rights (ICESCR) of the United Nations, as well as in other UN human rights treaties, the states commit themselves to ensuring adequate, non-discriminatory health care.

Usually, the government health ministries of the states are responsible for health care. Depending on the constitution and size of the states, there are both centralized and federal structures. But in most cases, parts of the overall responsibility are delegated to subordinate structures such as federal states, provinces, regions, and municipal units.

Even if the responsibility always remains with the (central) government in the end, health care institutions are organized very differently in the individual countries. In the United Kingdom, for example, the vast majority of health care facilities are part of the state-run National Health Service. In Germany, facilities can be privately owned or publicly owned, such as by cities and countries, but they are always subject to state supervision. The financing of the health care systems also differs. There are state-financed health care systems, systems of almost nationwide compulsory insurance for all citizens that bear the costs of care, or systems where citizens must bear the costs themselves. However, the differences can be quite fluid.

The network of health care in a state or region consists, as already mentioned in Sect. 2.6, not only of hospitals and medical offices but also of responsible government agencies and insurance companies, among other things. The global pandemic that broke out at the end of 2019 in particular highlights the importance of municipal health departments, national disease control authorities (e.g., the Robert Koch Institute in Germany), and international institutions (e.g., the European Centre for Disease Prevention and Control (ECDS) and the World Health Organization (WHO)). However, it also highlights the importance of networking among these agencies.

6.9.2 Technological Perspective

We already know from Sect. 2.6 that every state and region in which there is a network of health care facilities already has, by definition, a transinstitutional health information system (tHIS). However, such tHIS are supported by computers to quite different degrees depending on the country. Networking between actors requires communication and interoperability of the systems involved, just as it does within institutions. Very often—even in rich industrialized countries—this communication takes place by telephone or postal communication or even by fax.

The tHIS of states or regions are composed of the institutional information systems of the institutions participating in the network. These information systems thus incorporate the entire range of application systems described in Sect. 3.4 into the tHIS. In order for the institutional information systems to be interoperable with each other, they must each have interoperable application systems through which they can communicate with the other institutional information systems and thus work together. All aspects of interoperability and integration discussed in Sects. 3.7 through 3.10 play a role in this process, and use of the interoperability standards discussed in Sect. 3.7.2 is essential. For example, in Austria, and increasingly in Germany, Integrating the Health care Enterprise (IHE) profiles and especially XDS are used for this purpose (Sects. 3.7.2.5 and 3.7.2.6). However, FHIR is becoming increasingly important.

Especially for government agencies and ministries of health, other application systems are required in addition to those explained in Sect. 3.4. The WHO describes 25 types of such application systems in its WHO Classification of Digital Health Interventions [2]. However, at this point, the WHO’s terminology does not match the terminology in our textbook, so the application systems at WHO are usually referred to as information systems. Examples of such types of application systems are “community-based information systems” (WHO category F) and “public health and disease surveillance system” (WHO category V). The “district health information systems” frequently mentioned in the literature must also be understood as application systems that must work together with the other application systems of the tHIS via interfaces.

It makes sense if, in a national health care system and also at the international level such as the European Union, a computer-supported infrastructure is available at the physical (Sect. 3.10.2) and logical level of the tHIS through which the institutional information systems can communicate with each other in a standardized manner. In Germany, for example, this infrastructure is known as the telematics infrastructure.

Worldwide, tHIS are developed very differently at the country level. The level of development—sometimes called digital maturity—cannot be determined solely by the availability of modern IT. What matters most is whether this technology actually brings benefits to health care. A study conducted in 2020 therefore analyzed in various countries whether patients, their caregivers, and medical staff in hospitals or other facilities can read and enter the data required for health care. Even rich industrialized countries performed very poorly [3].

6.9.3 Management Perspective

Responsibility for tHIS at the state or regional level falls to the relevant government agencies. These are usually the ministries of health. The framework for tHIS development and responsibilities are defined by law.

Sometimes, as in Estonia, for example, there is a state chief information officer (CIO) who is also responsible for the nationwide tHIS of the health care system. In Estonia, this CIO is responsible for the national infrastructure and the use of communication standards. In other countries, like Finland, for example, responsibility for the national tHIS is decentralized and regional structures, for example, provinces or federal states have responsibility. In Germany, there is a company controlled by the Federal Ministry of Health, GEMATIK, which is responsible for setting up and operating the telematics infrastructure in the country.

6.10 Life Situations and Their Consequences for Orchestrating Services in Transinstitutional Health Information Systems

In Sect. 1.2, we already saw that people in different life situations are concerned about and have to deal with their health. These life situations are closely linked to the settings we discussed in the previous sections of Chap. 6. For example, prevention and wellness are closely linked to the different settings we discussed in Sect. 6.7 but also to personal environments (Sect. 6.8). Medical emergencies and acute illness are taken care of by both hospitals (Sect. 6.2) and medical offices in ambulatory care settings (Sect. 6.4). These settings are also there for the treatment of chronic illnesses, but it is precisely in this life situation that the personal environment and one’s own home also become therapeutic spaces where, for example, the attending physician comes for a home visit and patients acquire knowledge about their illness, seek advice via the internet, or plan necessary visits to the doctor and specialists (Sect. 3.3.1). Care of the elderly or people with chronic diseases takes place both in the nursing home (Sect. 6.3) and in the personal environment, if necessary with the support of an ambulatory nursing organization (Sect. 6.5). Rehabilitation facilities prepare patients for a more “normal” life after emergencies and acute illnesses but also when chronic illnesses improve.

This summary shows us clearly that people need very different health care services from different health care settings in different places during their lives. We introduced the notion of tHIS in Sect. 2.6, which summarizes the information processing in and between all these health care settings.

Ultimately, the challenge remains for each person to arrange for themselves to find the services they need in the tHIS and to ensure that the services fit together and are appropriate for treating their condition. Many are grateful when relatives and friends help with the search. GPs can also help to a limited extent.

In the context of service-oriented architectures (SOAs, Sect. 3.9.4), we are familiar with the need to compile required services when taking a technical view of health information systems. We refer to this as the orchestration of services. We can also apply this term to the challenge of citizens to find suitable medical services and combine them appropriately.

Given the complexity of medical services and the medical expertise required to orchestrate them, family doctors and hospitals, as already mentioned, take on part of the orchestration and organize, for example, the necessary visit to a specialist. We refer to this as provider-induced orchestration. But even with such support, patients will still need to independently seek appropriate transportation, i.e., other, non-medical services. And often, referrals to specialists will only specify the type of specialist; patients will have to find the exact person or facility themselves. So the patient is left with plenty of complex tasks, which we call patient-induced orchestration.

In this situation, it is very helpful if the information about offered medical as well as non-medical services is available for the citizens. But in the enormous complexity of transinstitutional health information systems and the abundance of corresponding information, not only elderly people are quickly overwhelmed with this patient-induced orchestration. The question arises to what extent information technology can also help to find the services needed in a particular health situation and ensure that they fit together. For example, it must be ensured that that specialists are selected only in such a way that they can be reached from patients’ homes by public transport during their consultation hours. Although there is promising research on this customer-induced orchestration, much remains to be done.

6.11 Example

To support medical research and care, the German Medical Informatics Initiative (MI-I) was launched. Four consortia of university medical centers are establishing the so-called data integration centers (DICs) for the individual hospitals. These DICs are facilities that extract data from the electronic patient records of the respective hospitals to make them available for research projects. Note that in each hospital, the data from the electronic patient records is scattered around the various application systems of this hospital. The consortium SMITH (Smart Medical Information Technology for Health care) decided to apply IHE to share data between the hospitals and the DICs as well as between the DICs of the different hospitals. For details, see [4].

Figure 6.4 shows the high-level functions to be performed and the entity types involved in a 3LGM² model. The dotted lines indicate that there are still refinements to the corresponding tasks and entity types. Patient data (“EMR Data in UH Sources”) is taken from the electronic patient records of hospitals (“University Hospital (UH)”) and inserted into a separate storage area. There, the data are prepared and, in particular, semantically “nourished,” i.e., enriched. Also, certain rules and methods for processing the data are managed in this “Health Data Storage.” When the patients to whom these data belong have given their consent, the data are pseudonymized by a trustee unit and made available to research projects by the “Transfer Management.”

Fig. 6.4

High-level functions and entity types of data integration centers in SMITH

At each DIC’s site, application systems are needed to support the local DIC, i.e., supporting the execution of functions as well as storing and communicating the entity types. Data and knowledge sharing between sites and between patient care and research projects (Research & Development Factory) have to be enabled. Communication is standards-based, especially using IHE profiles, CDA, FHIR, and SNOMED to ensure syntactic, semantic, and process interoperability.

The architecture of the local information system and their communication links at each site follows the DIC reference architecture as outlined in the 3LGM² model in Fig. 6.5. Using IHE profiles, the local sub-information systems of the entire tHIS of the SMITH network (SMItHIS) are integrated. While applying the DIC reference architecture locally, the reference architecture allows for local peculiarities.

Fig. 6.5

SMITH-DIC Reference Architecture at the logical tool layer

As mentioned before, the DICs have to ingest data from various data sources, i.e., different application systems of the local hospital information systems. Communication between application systems is classified into three categories, A, B, and C, according to their interface type (“if-type”) (see legend in Fig. 6.5). Sources of Type A are designed using IHE profiles. There are application systems that can serve HL7 and DICOM standards but do not fully implement IHE profile. They are referred to here as Type B sources. Type C sources are proprietary, such as data provided by comma-separated value (CSV) files.

The “Data Integration Engine” executes data transformation and load processes from sources into the health data storage (HDS). The HDS contains both a component for storing HL7 FHIR resources (Health Data Repository) and an IHE XDS document repository comprising clinical data in HL7 CDA documents. Using the interface-type scheme (A, B, and C), data are shared beyond department borders. Precise explanations of other details can be found in [4].

6.12 Exercises

6.12.1 Research Architecture

A clinical researcher at Ploetzberg Hospital has won a grant to set up a register for patients who have received a knee endoprosthesis. Disease registers are research databases for collecting data about a specific disease, aiming for full coverage of the respective patient collective. The aim of a knee endoprosthesis registry is to collect longitudinal data to find out which type of endoprosthesis works best over time. The researcher wants to integrate data from patient-reported outcome questionnaires, findings from inpatient or outpatient visits at the hospital, and results from laboratory examinations. Which entity types need to be integrated and from which application components do they come? Devise a plan how you would set up a sustainable research architecture, i.e., an architecture that also could be used in other research settings and for different disease or research entities, considering Sect. 6.6.

6.12.2 Medical Admission

In which of the health care settings above will the function medical admission need to be supported?