Presenting XML-based Medical Discharge Letters According to CDA

H. B. Bludau; A. Wolff; A. J. Hochlehnert

doi:10.1055/s-0038-1634382

Methods of Information in Medicine, Table of Contents

Methods Inf Med 2003; 42(05): 552-556
DOI: 10.1055/s-0038-1634382

Original Article

Schattauer GmbH

Presenting XML-based Medical Discharge Letters According to CDA

H. B. Bludau

¹Department of Internal Medicine, University of Heidelberg, Germany

,

A. Wolff

²Department of Medical Informatics, University of Heidelberg, Germany

,

A. J. Hochlehnert

¹Department of Internal Medicine, University of Heidelberg, Germany

› Author Affiliations

Abstract

Summary

The HL7 Clinical Document Architecture (CDA) is an important XML-based standard for the representation of clinical documents.

Objectives: The use of Markup Languages could satisfy the demands of involved healthcare staff as well as the needs of patients, to receive an overview of the patient’s treatment during the hospital stay. The standardization efforts of different groups dealing with this problem have demonstrated progress, but have not, as yet, achieved a routinely usable result. In particular, differentiating information according to a hierarchical order has not been published to date.

Methods: A retrospective analysis of 60 discharge letters from a cardiology ward (ward A) as well as 60 discharge letters from a gastroenterology ward (ward B) were extracted from the central hospital information system, by taking every fifth discharge letter issued over a one year period.

Results: An XML-based prototype for medical discharge letters has been put in place representing the required information units and information elements. By means of an XSL-stylesheet, a detailed representation of the conventional discharge letter has been produced that is platform independent and permits the recurrent use of information units.

Conclusions: Through the introduction of definitions like information elements and information units, progress in the development of CDA level two and three might be realized. We present a method by which discharge letters can be used by an Internal Medicine Department. This concept is implemented in a XML-based prototype allowing a special view on XML data to generate this document type.

Keywords

HL7 - CDA - XML - discharge letter

Full Text

References

References
1 Sokolowski R, Dudeck J. XML and Its Impact on Content and Structure in Electronic Health Care Documents. Proceedings / AMIA Annual Symposium. 1999: 147-51.
2 Hochlehnert A. Discharge letters under the aspect of longtime archiving. Master thesis, University of Heidelberg; 2002. (German only).
3 Fierz W, Grütter R, Eikemeier C. Declarative Programming with XSLT implemented on the Example of a Practical Healthcare Application. SMI 2001; 47,: 21-7.
4 Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer SL, Essin D, Kimber E, Lincoln T, Mattison JE. The HL7 Clinical Document Architecture. JAMIA 2001; 8 (Suppl. 06) 552-69.
5 Dolin RH, Alschuler L, Behlen F, Biron PV, Boyer S, Essin D, Harding L, Lincoln T, Mattison JE, Rishel W, Sokolowski R, Spinosa J, Williams JP. HL7 Document Patient Record Architecture: An XML Document Architecture Based on a Shared Information Model. Proc AMIA Symp 1999: 52-6.
6 Paterson GI, Shepherd M, Wang X, Watters C, Zitner D. Using the XML-based Clinical Document Architecture for Exchange of Structured Discharge Summaries. Proc. of the 35th Hawaii International Conference on System Sciences. 2002: 1-10.
7 Dolin RH, Alschuler L, Boyer S, Beebe C. An update on HL7’s XML-based document representation standards. Proc. AMIA Symp. 2000: 190-4.
8 Wolff A. Patient-centered documentation of malignant diseases. A generic XML-based information model for syntactically and semantically structuring cross-institutional electronic patient records. Doctoral thesis, University of Heidelberg; 2002. (German only).
9 Mludek V, Wolff A, Drings P, van der Haak M, Haux R, Wannenmacher M, Zierhut D. Integration of Clinical Practice Guidelines into a Distributed Regional Electronic Patient Record for Tumor-Patients using XML: A Means for Standardization of the Treatment Processes. Medinfo. 2001; 10: 658-62.
10 Renner H, Scheitz W, Gabor S. 2001 Patients Dismissal letter – No standard is the standard. Proceedings of the TEHRE 2001, 6th Annual European Health & IT-Conference and Exhibition on Electronic Health Records,. London 11.-14.01.
11 Gilbert Mohr.. D2D - Telematik Initiative der KV Nordrhein. Version 1.3. www.kvno.de , last access: 21.10.2002.
12 Heitmann K, Schweiger R. Dudeck J: Discharge and referral data exchange using global standards – The SCIPHOX project in Germany. International Journal of Medical Informatics, in preparation.;
13 Schmücker P, Ohr C, Beß A, Bludau HB, Haux R, Reinhard O. Die elektronische Patientenakte – Ziele, Strukturen, Präsentation und Integration. Informatik, Biometrie und Epidemiologie in Medizin und Biologie. 1997; 29 3-4 221-41.