The Worldly XDS

March 27, 2015
Some would say that the IHE XDS Profile is premature. World case studies examples may suggest otherwise, and that is it time for greater application of the profile in the U.S.

On multiple occasions I have been reminded by industry sources who would suggest that the IHE (Integrating the Healthcare Enterprise, profile known as Cross Document Sharing (XDS) is not yet widely accepted or implemented. 

Despite the slow adoption of the IHE XDS profile in the healthcare IT market, it and its derivatives (XDS-I, XDS-MS, XDS-SD, etc.) have become the de-facto approach for exchanging clinical information on a regional or national scales in most of Europe and Canada. Single payer countries foster collaborative care delivery models among primary and secondary care stakeholders and thus require a robust content-agnostic information exchange infrastructure. The procurement organizations in those countries strongly believe in the standardization and open approach towards interoperability as a method to prevent vendor lock-in as well as to future proof the purchased solution.

Recently, I had a productive conversation with Genady Knizhnik, VP Sales, North America, Forcare Canada Inc. ( Genady believes that US market should take a serious look at other countries’ clinical information exchange experience, which is becoming increasingly relevant under the current shift towards ACO and value-based care. Genady provided evidence that XDS is definitely a viable and worldly solution and sited multiple examples of XDS implementation that help substantiate that it is working in the real world.

XDS in the Northern Netherlands

An IHE white paper describes how as far back as 2011 hospitals in the regions Groningen, Friesland and Drenthe began to develop a plan for information exchange.  They developed a multi-stage plan for setting up a central XDS infrastructure, the integration and phasing out of the existing XDS infrastructures (there were already three in the region), replacing the flow of CDs, and continuing developments towards the exchange of reports and XDW (Cross-Enterprise Document Workflow).

The goal of the project was to set up one centrally housed XDS infrastructure for the region to enable the exchange of images, reports and requests.  The result is a generic regional XDS network covering Northern Netherlands, which can be connected to infrastructures of other regions, such as Twente (IZIT), Noord-Holland (ZorgrIng NHN), Amsterdam (EZDA) and dedicated national networks such as Mammo-XL.  For each healthcare institution a connection is made only once, on which subsequently multiple exchanges can take place. 

Medical Centre Leeuwarden

The Medical Centre Leeuwarden is the leading hospital for advanced clinical practice in Friesland and is the largest non-university teaching hospital in the Netherlands.  After extensive research the MCL made the choice in principle at the end of 2007 for the Cross-enterprise Document Sharing for Imaging (XDS-I).  The third and final phase, during which other hospitals in the region were linked to the cardiology network for clinical information exchange, was successfully completed during the course of 2009.  Adapting legacy systems and image archives to the integration profiles required for IHE XDS-I was achieved using products developed by Forcare B.V. in Zeist (The Netherlands).

Each hospital uses both forView (XDS document consumer) and forConnect (XDS document source) to interface to (legacy) cardiology and radiology PACS for publication and exchange of diagnostic quality images, ECGs and reports.  The Friesland Regional Cardiology Network speeds up the referral process, improves both diagnosis and the clinical decision process, and on average reduces by one or two days the length-of-stay for patients in hospitals.

NHS in Bristol

University Hospitals Bristol NHS Foundation Trust is first in a group of hospitals to make sure critical imaging is available at the point of care in a new way.  Since the introduction of IEP Connect and Share, clinicians have been seeking access in order to reduce unnecessary repeat imaging, reduce delays in treatment, and to enhance scheduling so that planned treatment can be carried out more quickly, while improving the quality of decision making.  With thousands of clinicians, medical secretaries, clinic administrators, and multi-disciplinary team (MDT) coordinators set to use the system at University Hospitals Bristol alone, the Connect and Share registry is also now being fed by North Bristol NHS Trust, Royal United Hospital Bath NHS Trust and The Royal National Hospital for Rheumatic Diseases, meaning much greater secure access to imaging than ever before.  IEP Connect and Share is built on the XDS data-sharing standard that has the potential to be scaled to a national solution for the NHS into the future.

Keystone Health Information Exchange

Keystone Health Information Exchange (KeyHIE) is a growing network of healthcare providers in 31 counties of central and northeast Pennsylvania, serving nearly 3 million patients, many in Medically Underserved Areas.  Geisinger Health System, an integrated delivery network recognized for its innovative use of healthcare IT-supported care coordination, is an original and active participant in KeyHIE.  Geisinger was awarded a $2.3 million grant from the Agency for Healthcare Research and Quality (AHRQ) to extend the KeyHIE-connected community to additional regional hospitals, long-term care facilities, home health organizations, and physician practices. In addition to attracting stakeholders, the five-year AHRQ grant is helping to make new clinical applications and document types available within the HIE.

KeyHIE selected GE Healthcare’s eHealth Solutions to power their community Health Information Exchange. Today, KeyHIE has nearly 3 million patients in the Master Patient Index (MPI) across the seven active hospitals.  Using GE Healthcare’s Information Exchange, KeyHIE adheres to IHE standards, which are thoroughly tested in North American Connect-a-thons, including Cross enterprise document sharing (XDS): an IHE standard to register, store and query/retrieve patient-centric documents located within the HIE, and Cross enterprise document sharing-scanned documents (XDS-SD): an IHE standard for sharing scanned documents located within the local HIE community such as discharge summaries, history & physical documents and radiology reports.

As these examples clearly demonstrate, the XDS standard is in fact actively being used across Europe and North America, including XDS-I for imaging.  (For further information on these and other success stories, see  Anyone contemplating enterprise image sharing across multiple entities should be seriously looking at XDS.  As usual, I welcome your comments and experiences, particularly those with positive as well as negative experiences with XDS and XDS-I.

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