Key Factors in Achieving Intersectoral Interoperability: A Scoping

Review

Eveline Prochaska

1,* a

, Franziska Bathelt

2,* b

, Michelé Zoch

, Antonia Ewald

and Elisa Henke

Institute for Medical Informatics and Biometry, Faculty of Medicine and University Hospital Carl Gustav Carus,

TUD Dresden University of Technology, Dresden, Germany

Thiem-Research GmbH, Cottbus, Germany

Keywords: Healthcare, Intersectoral Interoperability, Scoping Review.

Abstract: Intersectoral interoperability is a fundamental basis for effective collaboration and seamless information

exchange across various sectors of the healthcare system. This paper presents a scoping review to examine

the current state of research into intersectoral interoperability, focusing on the technical, syntactic, semantic,

and organizational levels. Key factors identified include the adoption of international standards for data

formats, terminologies, and communication protocols, as well as the establishment of trusted governance

structures and compliance with ethical and legal requirements. Syntactic interoperability was most frequently

addressed, followed by technical and semantic aspects, with organizational factors also playing a significant

role.

1 INTRODUCTION

Intersectoral interoperability refers to the ability to

seamlessly exchange and use information and data

across different sectors or domains to ensure

coordinated and effective care or collaboration

(Perlin et al., 2016). In healthcare, this particularly

means the integration and collaboration between

different actors and organizations that provide

different services or functions, such as:

 General practitioners and specialists: primary

and secondary care sector

 Hospitals: tertiary care sector

 Public health: for population health, with

system, political and organizational focus.

In this context, interoperability is crucial to

enabling holistic patient care, as it facilitates the

exchange of patient records, diagnoses, treatment plans

and other relevant information. This can improve the

quality of care, reduce redundant examinations and

https://orcid.org/0000-0002-7609-1565

https://orcid.org/0000-0002-4139-5489

https://orcid.org/0000-0002-5577-7760

https://orcid.org/0000-0002-5002-2676

* These authors contributed equally to this work

treatments, and optimize coordination between the

various players in the healthcare system. Intersectoral

interoperability requires consideration of the following

four levels of interoperability: (1) technical

interoperability to ensure data exchange between

systems through technical components; (2) syntactic

interoperability to ensure harmonized data formats and

information models; (3) semantic interoperability to

ensure a common understanding of message content

between systems and/or users and (4) organizational

interoperability to ensure that the exchange of

information is secure, effective, and compliant with

legal and data protection requirements (Rezaei et al.,

2014).

Despite technological advances and the

introduction of numerous IT solutions, the seamless

integration of information and processes remains a

challenge. This challenge arises from the diversity of

the systems involved, the differences in the

technologies used, and the varying standards and

protocols employed in different sectors.

914

Prochaska, E., Bathelt, F., Zoch, M., Ewald, A. and Henke, E.

Key Factors in Achieving Intersectoral Interoperability: A Scoping Review.

DOI: 10.5220/0013373500003911

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 18th Inter national Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2025) - Volume 2: HEALTHINF, pages 914-919

ISBN: 978-989-758-731-3; ISSN: 2184-4305

The aim of this study is to examine the extent to

which intersectoral interoperability is already being

addressed in the literature, including which core

aspects are particularly emphasized and whether

measures necessary for its implementation can be

derived. Building on this analysis, the study seeks to

develop a comprehensive understanding of the

complexity of intersectoral interoperability and to

formulate actionable recommendations for more

effective integration of the various healthcare sectors.

2 METHODS

To get an overview about current developments,

challenges and perspectives of intersectoral

interoperability in healthcare, we conducted a scoping

review. Our literature search focused on publications

describing intersectoral interoperability in the medical

field, especially the data exchange and/or collaboration

between different sectors of the healthcare system with

the aim of providing healthcare.

Table 1: Search strings used for the literature search in

PubMed and Web of Science.

Publication

database

Search string

PubMed

(medic* OR health*) AND (((intersectoral OR

inter sectoral OR inter-sectoral) OR

(crosssectoral OR cross-sectoral OR cross

sectoral) OR (multisectoral OR multi sectoral

OR multi-sectoral)) AND interoperability)

Web of

Science

(ALL=(medic*) OR ALL=(health*)) AND

(((ALL=(intersectoral) OR ALL=(inter

sectoral) OR ALL=(inter-sectoral)) OR

(ALL=(crosssectoral) OR ALL=(cross-

sectoral) OR ALL=(cross sectoral)) OR

(ALL=(multisectoral) OR ALL=(multi

sectoral) OR ALL=(multi-sectoral))) AND

ALL=(interoperability))

We followed the PRISMA guidelines (Moher et

al., 2009) and used two publication databases (i.e.

PubMed, and Web of Science) to search for relevant

publications until to May 30, 2024 (without starting

time limit) written in German or English

(Table 1).

This review was a two-step process consisting of a

title-abstract screening (TAS) and a full-text

screening (FTS). Both screening processes used the

same exclusion criteria listed in Table 2.

The screening team consisted of four reviewers

(FB, EH, MZ, AE). The TAS was carried out by two

reviewers (FB, EH) in Rayyan (Ouzzani et al., 2016)

blind mode so that each reviewer could label the

publication independently. The blind mode was

deactivated after all publications had been labeled and

the conflicts discussed and resolved. Thereafter, all

included publications were loaded as a new project

for FTS in Rayyan. The subsequent FTS was

conducted by four reviewers (AE, MZ, EH, FB).

Table 2: Exclusion criteria applied.

Description of criterion Label

Publication does not cover the medical

field in the sense of health care.

no_medic

Publication cites medical field as just one

otential area of application.

medic_

mentione

Publication does not deal with

intersectoral interoperability; it only

considers one sector (e.g. hospitals) or no

data exchange with the aim of healthcare

provision. This category also includes

telemedicine systems that do not focus on

combining data from different sectors.

no_intersec_

interop

Publication only mentions (intersectoral)

interoperability as a potential field of

application.

intersec_

interop_

mentione

Publication is available in a language

other than German or English.

foreign_

language

Publication is only an abstract, a keynote,

a letter to the editor or a tutorial.

wrong_publicati

ontype

Publication is not accessible or available

as full text.

no_fulltext

The FTS was also conducted in blind mode and

followed the same review process as the TAS. After

the FTS, we extracted the content of all included

publications based on the categories listed in Table 3.

The extracted content was stored in a table to enable

further analyses.

Table 3: Categories for data extraction.

Categor

Description

Countr

Country of the considered system

Connected

healthcare

roviders

Home, Hospital, General Practice,

Public Health Institutions

Level of

implementation

Concept, Proof of Concept, Routine

Technical

interoperability

aspects

How is technical interoperability

achieved?

Syntactical

interoperability

aspects

How is syntactical interoperability

achieved?

Semantical

interoperability

aspects

How is semantical interoperability

achieved?

Organizational

interoperability

aspects

How is organizational interoperability

achieved?

Further

interoperability

categories

and aspects

Are there other categories named in

publication? (How is interoperability in

this category achieved?)

Key Factors in Achieving Intersectoral Interoperability: A Scoping Review

915

3 RESULTS

The literature search resulted in 113 publications.

After removing 17 duplicates, 96 publications were

screened during the TAS. By using the exclusion

criteria defined in Table 2 29 publications were

included for FTS. The screening process and results

are detailed shown in Figure 1.

Figure 1: PRISMA flow diagram according to (Haddaway

et al., 2022).

Finally, 12 studies were included in this review,

which are listed in Table 4 and assigned the sequence

numbers 1 to 12 for further analysis. A complete list

of the results of the literature search is available on

Zenodo (Henke, 2024).

The studies included in this review were

published between 2009 and 2021 and considered

healthcare providers from the following countries:

Denmark, Germany (3), Italy, USA (2), Haiti, Chile,

Thailand, Australia and worldwide. Furthermore, the

providers involved in intersectoral health care were

extracted. In all 12 studies, these were general

practices, in 11 studies hospitals, and in 7 studies

public health institutions. According to the predefined

extraction criteria (Table 3) the level of

implementation resulted in 4 concepts, 3 proof of

concepts and 5 routine uses.

The following Table 5 shows the methods

described in the studies for implementing

intersectoral interoperability in accordance with the

four previously defined interoperability levels. The

numbers 1 to 12 after each method indicate that this

method was considered in the respective study. Table

5 thus provides an overview of the various methods

for implementing interoperability and the frequency

with which these methods are applied.

Table 4: Studies included in this review.

Publication title and reference Number

A shared electronic health record: lessons from

the coalface (Silvester & Carr, 2009)

Chile´s National Center for Health Informatio

stems

(

urro et al., 2017

)

Cross-enterprise interoperability (Bauer et al.,

2020

)

Fosterin

lobal data sharin

(

Austin et al., 2020

)

Informatics for public health and health syste

collaboration (Lenert et al., 2021)

Interoperability after deployment (Kierkegaard,

2015)

Steps towards a digital health ecostystem

(

Serbanati et al., 2011

)

Success factors for implementing and sustaining

a mature electronic medical record in a low-

resource setting (deRriel et al., 2018)

The nephrology eHealth-system of the

metropolitan region of Hannover (Pape et al.,

2019)

The role of Integrating the Healthcare Enterprise

(

IHE

)

in telemedicine

(

Ber

h et al., 2015

)

The Strategic Implementation of Dat

Interoperability for Better Health Care Services

in Thailand (Kawtrakul et al., 2012)

Utilizing Standard Data Transactions and Public-

Private Partnerships to Support Healthy Weigh

Within the Community (Mikles et al., 2017)

Another additional aspect of interoperability

mentioned in three studies is the need to ensure an

adequate budget (e.g. for hardware, software, change

management, continuous training and ensuring

sustainability; 1,8,11). Without sufficient funds,

intersectoral interoperability cannot be achieved,

making the necessary budget a prerequisite.

On a technical level, web-based services such as

centralized databases, platforms and clouds are the

most frequently mentioned factors (67% of the

studies). International standards such as HL7 or IHE

for communication protocols and message formats

also play an important role (58%). These aspects

make it clear that a stable technological foundation is

essential to enable intersectoral exchange.

The semantic layer is heavily influenced by

international standards for terminology and

classification (67%). These ensure a unified language

and a common understanding between the actors

involved. The importance of shared repositories for

standardizing terms is mentioned less frequently

(25%), but it remains a valuable element for

improving interoperability.

HEALTHINF 2025 - 18th International Conference on Health Informatics

916

Table 5: Methods used for implementing intersectoral

interoperability.

Interoperability level

Mentioned in

stud

numbe

Sum* (in

)

Technical intero

erabilit

web services (centralize

databases, platforms, clouds,

server, public key infrastructure)

for communication

1, 3, 5, 6, 7,

8, 9, 11

8 (67)

international standards fo

communication and message

format

(

i.e. HL7, IHE, …

)

1, 3, 5, 8, 10,

11, 12

7 (58)

Semantic intero

erabilit

international standards fo

terminology and organization

systems, such as classifications

1, 2, 3, 8, 9,

10, 11, 12

8 (67)

shared repositories to enable

standardization of terms an

metadata

3, 4, 7 3 (25)

Syntactic interoperabilit

international standards for dat

exchange formats

1, 2, 3, 4, 5,

7, 8, 9, 10,

11, 12

11 (92)

anizational intero

erabilit

trusted entity/authority for projec

and s

stem mana

ement

1, 2, 6, 11 4 (33)

affinity domains (by IHE, SOA

latform, …)

3, 7, 9, 10 4 (33)

guidelines for compliance with

local legal and ethical

requirements for data

rocessing

and stora

1, 4, 11, 12 4 (33)

unique national patient identifie

(

i.e. master

atient index

)

3,5,10 3 (25)

technology monitoring procedures

and licensing or certification o

software

2, 4 2 (17)

* of total 12

With 92% of the studies referring to international

standards for data exchange formats, syntactic

interoperability is the most widely recognized key

factor. This high figure shows how important

standardized data formats are for the harmonization

of different systems.

At the organizational level, the role of trusted

authorities (33%) and guidelines for compliance with

legal and ethical requirements (33%) are central. Less

frequently mentioned, but still significant, are the

introduction of national patient identifiers (25%) and

procedures for monitoring and certifying

technologies (17%).

4 DISCUSSION

The aim of this study was to examine which key

factors are addressed in the literature to ensure

intersectoral interoperability. The analysis of the 12

scientific studies highlights central factors that are

important for successful intersectoral

interoperability. These can be assigned to the four

levels of interoperability – semantic, syntactic,

technical and organizational. The goal of the research,

to capture the key factors for a functioning

interoperability, is supported by these results, as they

shed light on specific requirements and measures for

each level.

Summarizing all but one of the studies mentioned

the importance of syntactic standards, followed by

semantic standards and components of the

infrastructure for communication and technical

standards. Factors of organizational interoperability

are only found in approximately one-third of the

publications considered. Assuming that

organizational aspects are absolutely necessary to

achieve interoperability, it can be considered the

included studies did not report all necessary aspects.

The research only considers scientific literature

and disregards national programs, which are often the

driving force behind intersectoral interoperability

activities. Programs such as national health initiatives

or electronic health record projects play a key role in

promoting interoperability, but were not analysed.

This limitation could affect the comprehensiveness of

the identified factors. Nevertheless, the results of the

studies provide valuable insight into evidence-based

approaches and provide a solid foundation for further

research.

In summary, no general statement can be made

about the measures necessary to ensure intersectoral

interoperability. However, the literature showed that

the implementation of intersectoral interoperability

requires the consideration of actions at all four levels

of interoperability.

5 CONCLUSIONS

The scoping review examined the presence of

intersectoral interoperability in the literature. The

core aspects and measures for implementing

intersectoral interoperability were presented. It was

shown that aspects of syntactic interoperability were

mentioned most frequently, followed by technical and

semantic interoperability. Activities to implement

organizational interoperability are reported least.

Key Factors in Achieving Intersectoral Interoperability: A Scoping Review

917

The identification and presentation of the key

factors makes it clear that intersectoral

interoperability is based on a combination of

technological standards, uniform data formats,

terminological systems and organizational structures.

Future research should supplement the scientific

literature with findings from national programs to

obtain a more comprehensive picture of the factors

and challenges.

It is evident that further research, incorporating all

four levels of intersectoral interoperability is needed

to gain a more comprehensive understanding of this

subject.

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