Summary
Objectives:
The exchange of medical data from research and clinical routine across institutional
borders is essential to establish an integrated healthcare platform. In this project
we want to realize the standardized exchange of medical data between different healthcare
institutions to implement an integrated and interoperable information system supporting
clinical treatment and research of glaucoma.
Methods:
The central point of our concept is a standardized communication model based on the
Clinical Document Architecture (CDA). Further, a communication concept between different
health care institutions applying the developed document model has been defined.
Results:
With our project we have been able to prove that standardized communication between
an Electronic Medical Record (EMR), an Electronic Health Record (EHR) and the Erlanger
Glaucoma Register (EGR) based on the established conceptual models, which rely on
CDA rel.1 level 1 and SCIPHOX, could be implemented. The HL7-tool-based deduction
of a suitable CDA rel.2 compliant schema showed significant differences when compared
with the manually created schema. Finally fundamental requirements, which have to
be implemented for an integrated health care platform, have been identified.
Conclusions:
An interoperable information system can enhance both clinical treatment and research
projects. By automatically transferring screening findings from a glaucoma research
project to the electronic medical record of our ophthalmology clinic, clinicians could
benefit from the availability of a longitudinal patient record. The CDA as a standard
for exchanging clinical documents has demonstrated its potential to enhance interoperability
within a future shared care paradigm.
Keywords
Computerized medical records - integrated health care systems - glaucoma - standardization
- clinical document architecture
