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This work is a report on practical experiences with the issue of interoperability in German practice management systems (PMSs) from an ongoing clinical trial on teledermatology, the TeleDerm project. A proprietary and established web-platform for store-and-forward telemedicine is integrated with the IT in the GPs’ offices for automatic exchange of basic patient data. Most of the 19 different PMSs included in the study sample lack support of modern health data exchange standards, therefore the relatively old but widely available German health data exchange interface “Gerätedatentransfer” (GDT) is used. Due to the lack of enforcement and regulation of the GDT standard, several obstacles to interoperability are encountered. As a partial, but reusable working solution to cope with these issues, we present a custom middleware which is used in conjunction with GDT. We describe the design, technical implementation and observed hindrances with the existing infrastructure. A discussion on health care interfacing standards and the current state of interoperability in German PMS software is given.
Background
Although teledermatology has been proven internationally to be an effective and safe addition to the care of patients in primary care, there are few pilot projects implementing teledermatology in routine outpatient care in Germany. The aim of this cluster randomized controlled trial was to evaluate whether referrals to dermatologists are reduced by implementing a store-and-forward teleconsultation system in general practitioner practices.
Methods
Eight counties were cluster randomized to the intervention and control conditions. During the 1-year intervention period between July 2018 and June 2019, 46 general practitioner practices in the 4 intervention counties implemented a store-and-forward teledermatology system with Patient Data Management System interoperability. It allowed practice teams to initiate teleconsultations for patients with dermatologic complaints. In the four control counties, treatment as usual was performed. As primary outcome, number of referrals was calculated from routine health care data. Poisson regression was used to compare referral rates between the intervention practices and 342 control practices.
Results
The primary analysis revealed no significant difference in referral rates (relative risk = 1.02; 95% confidence interval = 0.911–1.141; p = .74). Secondary analyses accounting for sociodemographic and practice characteristics but omitting county pairing resulted in significant differences of referral rates between intervention practices and control practices. Matched county pair, general practitioner age, patient age, and patient sex distribution in the practices were significantly related to referral rates.
Conclusions
While a store-and-forward teleconsultation system was successfully implemented in the German primary health care setting, the intervention's effect was superimposed by regional factors. Such regional factors should be considered in future teledermatology research.