The Electronic Health Record (ELGA) in Austria
1. Political and legal basis
The ELGA Act 2013 provides the specific legal basis for processing health data by means of
an electronic health record and reenacts the health telematics Act
(Gesundheitstelematikgesetz) 2005. It contains rules for the provision of ELGA’s central and
decentral components (i.e. the so called affinity domains) and for the procession of health
data by the health service providers as well as technical and organizational norms such as
time lines for the duty to use ELGA for different groups of health care providers and specified
classes of ELGA data. The ELGA Act also provides for patient service institutions such as
the service line by telephone and the ELGA Ombud.
The political will, however, was already manifested in 2008 when the federal entity (Republik
Österreich), the nine provinces (Bundesländer) as well as social security committed
themselves to setting up and implementing the electronic health record in Austria within a
framework treaty on the organisation and financing of the Austrian health system. This
commitment was reiterated in a more specific manner in further similar agreements such as
the so called “Bundeszielsteuerungsvertrag” containing main targets aiming at the reform of
Austrian health care. Consequently, an implementation organization (ELGA GmbH) was
founded in 2009 on private law basis but owned by the above mentioned governmental
partners namely the federal entity (Republik Österreich), the nine provinces (Bundesländer)
and social security.
2. The phasing in of ELGA in Styria and Vienna
Although the initial master plan foresaw the parallel start of ELGA in all nine provinces by the
beginning of 2015, it turned out in the course of the year 2014 that this would not be feasible
due to technical and organizational obstacles. Therefore, a gradual phasing in was agreed
upon. With respect to their highly advanced technical standards and long lasting experience
in e-health, the provinces of Styria and Vienna (which is also the country’s capital city) where
chosen to be pioneers. The connection between the affinity domains run by their hospitals
and the central components of ELGA is due in the beginning of December 2015. By that
time, ELGA related medical data which are saved on a Viennese hospital server will be ready
to be retrieved by doctors in Styria and vice versa. Furthermore, there will be a pilot
implementation of e-medication to be tested by physicians, the pharmacies and a local
hospital in the Styrian region of Deutschlandsberg. The other provinces as well as hospital
groups run by by social security, the church or the private sector, are to follow in the course
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of 2016. Furthermore, mobile care as well as care centers will be enabled to use ELGA,
albeit mainly as document consumers rather than as document source.
Detailed time-line:

Go live of the first two affinity domains (ELGA-Bereiche) in Styria and Vienna due in
December 2015

At the same time, the ELGA-Portal will have more features
 Access to medical documents
 Patients will be able to exercise their rights such as access to their own data and
blocking HCP from access as well as deleting links to data within the ELGA system
(not the data as such)
 Enhanced access to the protocol

In the first half of 2016 the affinity domains of Lower Austria, Carinthia and Social
Security will go live

e-Medication testphase in the 2nd term of 2016 in the district Deutschlandsberg, Styria

Go-live of further affinity domains in the course of 2016

ELGA-Verordnung (ordinance by the minister, based on the ELGA Act) will provide for
security standards and dates of duty to use ELGA for HPCs.
3. The ELGA portal
As of today, the only component visible to the end user is the ELGA internet portal at
www.gesundheit.gv.at which currently allows citizens to partially or generally opt out of ELGA
(due to privacy law restrictions) and to opt in again, if they wish to do so. In the near future,
the revamped and enlarged portal will give citizens and patients an easy and safe access to
their own ELGA related health data on a permanent basis as well as a tool for authorization
management and control of retrievals through the protocol.
The portal is being developed along the lines of the Austrian IT-strategy
[http://www.digitales.oesterreich.gv.at/], which provides electronic services in the public
sector for the citizen and will be divided into two parts:
Information portal: A generally accessible website with high quality health information for
citizens which is already online.
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ELGA Access portal: A restricted area gives the patient access to his or her personal ELGA
documents, applications as well as to the safeguarding functions for the patient’s rights. This
part of the portal is to date under construction.
The main features of the ELGA Access Portal are:
Authentication: The citizen / patient can register by means of the so called Citizen Card, a
new technology which is already broadly used in e-Government
[http://www.buergerkarte.at/index.en.php]. In order to access his or her electronic health
record, the citizen can either use the personal Citizen Card or a transaction code on the
mobile phone.
Access management: The citizen can authorize doctors and nurses to access his or her
health data in ELGA and define the expiry date of the authorization. This feature of the ELGA
portal contributes to patient autonomy and the enforcement of patient’s rights.
Document retrieval: The patient can retrieve his or her personal health data, print
documents and download them to personal devices.
Usability and Accessibility are key issues of the successful implementation of the ELGA
portal. In order to reach broad acceptance, the principal stakeholders and especially citizens
and patient groups have been integrated in the making of the ELGA portal from the very
start.
4. ELGA’s technical set up (“IT-Architecture”)
Austria’s constitution as a federal state consisting of nine provinces (Länder) and one federal
entity (Bund) requires ELGA to be implemented as a distributed IT system. Generally
speaking, ELGA provides for a decentralized storage of health data (e.g. test results, medical
images) in repositories within the respective organisation of origin. The few central
components are for the identification of patients and health service providers as well as for
authorization management.
The ELGA application “e-medication” is also featuring a central data base, the so called emedication account which will be provided by social security.
The above mentioned “organisation of origin” is also called “ELGA area” (ELGA Bereich) for
the benefit of project management. However, the technical term is “affinity domain” according
to the terminology of the „Integrating the Healthcare Enterprise Initiative” (IHE) a set of selfregulation rules stemming from health-IT industry which are being applied in ELGA. Sharing
of health data follows the “pull” rather than the “push” principle and takes place within one or
more affinity domains (e.g. a network of hospitals or private practices). These provide the
following functions:
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Unambiguous patient identification The Affinity Domains are linked by means of the
Centralised Master Patient Index (C-MPI) and ensure the common and unambiguous patient
identification. The C-MPI contains the demographic data of patients / citizens as well as the
Record Locator Service which locates the ELGA area where a patient’s health data are being
stored.
Identification of the health service providers: The proper set up of a treatment context
requires the unambiguous identification of the organisation where the treatment takes place
and of the involved physician or nurse alike. The identity management of those who carry out
medical treatments is allocated in the Centralised Healthcare Provider Index
(C-HPD).
Document Management: The core of every ELGA Area is the Repository for the storage of
ELGA documents (such as test results and medical images) whereas the Document Registry
contains only Meta data and links to ELGA documents. The ELGA Documents are structured
and classified according to the CDA-Levels (Clinical Document Architecture – see beyond).
The Central Authorisation System is the key component for the storage of roles and rights
and thus the basis for the strictly security oriented access management of ELGA.
5. Clinical Document Architecture (CDA): The key to the
harmonization of health data structure
The information contained in the ELGA documents shall not only be read by authorized
health service providers. It shall also be usable in their IT systems (so called „semantic
interoperability “).This goal cannot be reached by using customary document formats which
tend to be prone to malware attacks. Therefore, the Clinical Document Architecture (CDA),
Release 2 was stipulated as the relevant document standard. The CDA standard was
developed on an XML basis in 2005 by Health Level Seven International (HL7). Meanwhile, it
has been recommended by the Austrian Federal Health Commission (in 2007) and has
become a reference standard for the public procurement directive of the European Union.
Medical content is normally strictly separated from administrative content within a CDA
document. Merely administrative data and the document metadata are located in the socalled “CDA header“. The “CDA body“ contains medical information in a human-readable
format. In addition, machine-readable data can be embedded in order to support semantic
interoperability. This approach has many advantages:

CDA Documents can not only be displayed on the PC screen and printed as usual but
single data from the document can also be imported into the recipient’s IT system.

Information on specific conditions, e.g. on allergies and on medication doses can be
automatically integrated in the particular documentation of a health service provider.
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
Test results can be used for calculations.

Risks can be highlighted automatically.
The nationwide specification process for CDA documents has been going on since 2007 in
three working groups coordinated by ELGA GmbH and its predecessor. The main
stakeholders of the Austrian health system, amongst them representatives of the Austrian
Chamber of Doctors, nurses and physicians from both the primary and secondary care
sector, the social security, hospital providers as well as the software industry, medical data
exchange platforms and academics volunteered in this “national harmonization process”. In
total, approximately 200 persons were involved.
The working groups started with the most frequently produced and exchanged classes of
documents, i.e. the “Physician’s Discharge Summary” and the “Nursing Discharge
Summary“, the “Laboratory Report“ and the „Diagnostic Imaging Report“ and elaborated
them on a consensual basis. The “Pathology Report“ and the “Patient Summary“ will be
completed soon.
The harmonization work is compiled in the so called „CDA Implementation Guides“.
Technical instructions with relevance for all documents in ELGA are specified in a „General
Implementation Guide”: The syntax and the basic data types, as well as the structured
declaration of document title, patient and encounter, author, data enterer, authenticator,
other participants and similar information belong to the document header. Instructions with
relevance for clinical information, however, are compiled in specific Implementation Guides
for the different document classes. The CDA toolkit is completed by a reference terminology
server (which is operated by the Ministry of Health) as well as by so called reference style
sheets which help users to apply key rules while allowing them a maximum leeway in
implementation in their respective organization.
6. The benefits of e-medication: An outlook
Scientific studies prove that medication constitutes a main source of error in therapy
management. One of the reasons is the high degree of complexity. Proper medication needs
close cooperation between the secondary/acute care and the primary/community care
sectors as well interdisciplinary collaboration between physicians, pharmacists and nurses.
Beyond that, the risks of polymedication are not to be underestimated. Due to the increasing
number of drugs, there is a growing possibility of redundant prescriptions, interactions,
adverse impacts and erratic doses. Errors in medication often lead to hospitalization.
There is already scientific evidence for the potential and the advantages of an electronically
supported medication process. For this reason, e-medication was chosen to be the first
ELGA application.
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The citizens in Austria will be provided with an “e-medication account” with standardized
interfaces to the existing IT systems of pharmacies, private practices and hospitals. The
Health Service Provider will have an updated overview on prescribed and dispensed
medication which allows for an easier control of interactions. Polyprescription and
polymedication which can seriously endanger a patient’s health can thus be avoided.
Citizens will be able to access their personal “e-medication account” via the ELGA portal and
retrieve e.g. their current list of medication.
7. Summary of expected benefits of ELGA:

Optimised therapy by improved collaboration: The functions of ELGA will facilitate the
referral, hospitalisation and discharge processes and – above all – enable doctors to
have relevant medical data ready when treating a patient – in the primary and the
secondary care sectors alike. The increase in the efficiency of medication management
will be described in detail in chapter seven.

More quality through better knowledge: Allergy tests, information on the blood group,
images, summaries of laboratory and radiology tests, former test results showing
developments, lists of prescribed and dispensed medication are the elements that form
the puzzle of a patient’s condition. ELGA aims to provide the full picture and thus enable
doctors and nurses to fully use their curative potential without being distracted by the
absence or inaccessibility of relevant facts.

Patient empowerment: ELGA aims to support a patient centred approach. ELGA is
expected to have positive impacts on patient autonomy and patient safety e.g. by the
patient’s easy access to his own health records and medication lists and by the reduction
of waiting times, redundant examination and medication.

Easier workflows: The technical network of ELGA will enable the people working in
private practices, hospitals, nursing homes and health centres to act as reliable and
committed sources and consumers of health data und thus improve their communication.
Their common benefit will lie in easier workflows and enhanced, better structured
information. The time and energy saved from the often burdensome document
management can be directed towards the patient’s needs.
Despite considerable resistance from the medical doctors’ side, patient self-help groups,
patient ombud and other parts of civil society, namely the elderly (Pensionistenverband;
Seniorenbund) keep pushing for a speedy implementation of ELGA which they consider a
useful tool for achieving patient autonomy according to WHO guidelines.
Philippi, ELGA GmbH, 29.10.2015
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