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Objectives: In 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., Methods: In 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., Results: After 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., Discussion: The 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.

Today, information processing in healthcare facilities is usually primarily directed towards the information needs of the respective institution. This stands in apparent contradiction to the fact that patients may not be solely treated in one general practice or hospital. More information processing towards patient-centered, shared care would better support high quality as well as efficient health care. We developed a stepwise approach transforming trans-institutional information system architectures (TISAs) from an inefficient state caused by redundancy and media cracks towards a state which better supports patient centered, shared care. In a total of three steps we want to establish electronic communication between existing information systems of different healthcare facilities for transmission of discharge summaries and diagnostic results. In further stages we plan to expand this communication solution to a regional comprehensive and consistent electronic patient record for multiple hospitals and general practices in Tyrol, Austria. In addition, two related approaches towards supporting shared care have been compared with our approach. The aim of this paper is to report on our approach and first experiences.