This document summarizes a presentation given by Frank Löber on the current implementation and technologies used for a secure network connecting 50,000 physicians in Germany. It describes the initial fragmented situation, the developed solution including encryption methods, a core module for integration, authentication processes, and the data center. It notes that over 10,000 physicians are now using the system to transmit over 500 million medical records quarterly between physicians and insurance funds in a standardized way.

1. First US-German Summit on Primary Care
Current Implementation and Technologies
of a Secure Network für 50,000 Physicians
in Germany
Frank Löber
CIO/ CTO HÄVG Rechenzentrum
Washington, 9th April 2010
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2. Agenda
Initial Situation in Germany – Facts & Figures
Overview current solution in Germany for 50,000 Physicians
Current Situation & Next Steps
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3. Initial Situation in Germany
Fact & Figures
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4. Initial Situation in Germany
Fact & Figures
New reimbursement system (payment system) since June 2008
50,000 familiy physicians & 70,000,000 sick fund covered people
160 sick funds, recently substantial decrease in number due to
mergers
60 different software-solutions (doctor´s IT-system) for familiy
physicians with different operating systems
Different ways of communication (paper, CD-Rom, online)
High requirements for data protection for transmission and
storage
Main medical data to transfer: reimbursement items, diagnoses,
drugs, referrals, form-data
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5. Initial Situation in Germany
Billing Process in new reimbursement system
Documenting Send
Receive
medical data medical
Physician billing &
(diagnoses, data by
Payment
drugs ..) software
Check &
Hausaerzte- clearing Create
verband data & billing &
create and send it & do
(Clearing) send billing payment
file
Check
Sick Fund billing file &
Payment
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6. Initial Situation in Germany
Different business needs for different parties
Physicians:
No additional costs for hard- & software, software must be easy to
use
Software-Developers / Manufacturers:
Easy integration, installation & configuration of new software
Hausaerzteverband:
scalable solutions, authenfication of physicians, exchange
medical data between family and special physicians, increase
quality of primary care
Sick Funds:
Reduce costs of drugs and remedies, increase quality of primary
care
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7. Initial Situation in Germany
Legal Requirements for protection & authentification
High requirements for data protection & authentification:
Files with medical and personal data must be encrypted
Transmission must be encrypted
Files with medical data must be signed by a physician
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8. Initial Situation in Germany
Conclusion
Regarding all business needs of all parties means:
Development of a specific software-module („Core“)
without GUI for integration in existing software-solutions
Development of requirements and technical specifications
for existing software-manufacturers
Develop own software with GUI for physicians with basic
functions to manage our contracts (stand alone solution)
Usage of this software is part of our contracts
Develop own data-center
Develop own infrastructure to connect doctors for data
exchange
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9. Developed Solution in Germany
for 50,000 Physicians
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10. Transmission & Encryption
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11. Current Solution – Encryption & Transmission
Medical Data from doctor´s practice to data center
2 ways of online transmission:
Hardware-Router
with certicate of
doctor´s practice
Software-VPN with
certicate of doctor´s
practice
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12. Current Solution – Encryption & Transmission
Transmission Encryption
Secure Communication between doctors practice and our
data-center based on legal requirements using:
IPSec-Tunnels
Secure TLS-Connections
Key-Exchange-Protocol: Diffie-Hellman
Digital Certificates: X.509 (v3) Certificates with 2048 Bit key-length
Software VPN is based on OpenVPN (open source)
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13. Current Solution – Encryption & Transmission
File Encryption
Medical data (reimbursement items, drugs, …) will be
compressed and encrypted with a hybrid method before
transmission
Payload (Content of the file) will be symmetric encrypted
with AES (Advanced Encryption Standard) with 256 Bit key-
length
Encryption Key will be asymmetric encrypted with the public
certificate of the receiver with 2048 Bit key-length by SHA1-
RSA
Data will only decrypted in our data-center
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14. Core-Module
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15. Current Solution – Core-Module
Overview Technical Solution
Doctor`s Practice
Usable on
clients,
Doctor´s servers and
IT-System as ASP- Core Online-Updates Data-
Solution Center
Core-Functions
HTTPS
VPN
XML Konnektor
SOAP
Contract Contract Contract
1 2 3
Open
VPN
Modular specific Contract-Data using open
source database SQLite
Database Modules Software Run Time Environment Interface
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16. Current Solution – Core-Module
Functions
Validate medical data in doctor´s practice
Provide steering algorithms i.e. substitutions
for low priced drugs
Provide specific data i.e. special Core
catalogues of ICD10-diagnoses
Provide Online-Services i.e.
„check enrolled patients“
Encrypt medical data before transmission
Receive daily-updates Existing
No graphical user interface Software Core
with GUI
Easy to integrate in existing software solutions
Defined data structure for medical data
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17. Example for drug substitution
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18. Current Solution – Core-Module
Example for Substitution Drugs I / III
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19. Current Solution – Core-Module
Example for Substitution Drugs II / III
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20. Current Solution – Core-Module
Example for Substitution Drugs III / III
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21. Authentification
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22. Current Solution – Authentification
Doctor & Practice
Authentification is used for following purposes
Identification
Signing medical data
Current Solution: Rollout of software-based certificates
Planned: Rollout of hardware-based certificates
(health professional card)
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23. Data-Center
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24. Current Solution – Data-Center
Overview of Services
Provide Online-Services i.e. „check enrolled patients“
Receive data from the physicians
Approval & Decryption & Clearing & Storage
Billing & Accounting-Services
Provide Online-Updates
Interfaces to several Sick Funds for data exchange
Exchange Data in XML
Multiple & Mass Data Processing
Provide Trust Center to manage certificates
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25. Current Situation & Next Steps
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26. Current Situation & Next Steps
Using our system since June 2008
2,000 physicians using Hardware-Router, 8,000 physicians using
Software-VPN for transmission encryption
10,000 integrated Cores in existing 35 software-solutions
6,000,000 insured persons are enrolled in the new system
500,000,000 medical data, diagnoses, drugs, remedies, referrals
every 3 months to validate
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27. Current Situation & Next Steps
Provide Core-Module in Java
Provide Core-Module as ASP-Solution
Provide billings for doctors online as PDF to download
30,000 physicians and 30,000,000 insured persons in the new
system
And…. It will work!!!
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28. Questions & Answers
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29. Thanks for your attention
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