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XML in healthcare computing
the potential
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Abstract
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From time to time there is a landmark development that revolutionises
the way that we live, the things we do and the way in which we do them. One
of the most significant developments of the last part of the last century
was the computer. In previous centuries, the book (paper) had an equally significant
impact. Both are currently used for the recording of clinical information.
Will XML finally allow the computer to replace paper in the recording
of clinical information?
Will XML itself be considered a landmark development?
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Contents
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Introduction
Until relatively recently, the book (paper) has been regarded as the
easiest, most cost-effective way to record clinical information. At the sharp-end
of care delivery, the real clinical information has been routinely recorded
in the well-loved and trusted paper record. However, there is now a drive
to deliver care closer to the patient, rather than only in institutions such
as hospitals, this means a more portable, sharable clinical record is needed.
In the UK hospital trusts mergers have resulted in specialist clinical
services being centralised. For example orthopaedic services could be provided
at one hospital five miles from another providing elderly care to the same
population.
Capturing and storing clinical information in paper does not provide
the responsiveness or flexibility required to meet the needs of healthcare
professionals working in this new environment I believe that computerising
clinical information is the only way that we can effectively deliver this
fragmented care.
XML is the tool that brings computers into the front-line of clinical
records and knowledge management. XML alone is not the total answer, but it
offers us the ability to pull information from wherever it is stored and present
it in any way demanded by healthcare professionals. We do not have to get
rid of our legacy systems – we just need to capture the output from
them in a standardised way.
Previous
Table of Contents
Information for Health
Information for Health outlined the strategy for developing IT in the
NHS over the next 5 years (2005).
One of the main objectives of the strategy was to develop an EPR in every Trust.
At this stage let me clarify how the acronym EPR is
used in this context. The EPR programme
concluded that it’s objective was not to produce an electronic record.
Not to re-create the paper record electronically but rather to support clinical
care with computers. In this way, not only is the record of that care produced
automatically, but it is more accurate.
The EPR (as
depicted in Information for Health) requires the systematic incremental development
of linked or integrated clinical systems to be developed with the prime objective
of supporting clinical care in real-time.This will often still need the larger
traditional systems. The internet/browser solutions have their place but will
not, for the foreseeable future provide a complete solution I believe that
XML provides a great opportunity to create conformity from diversity. We won’t
need to impose national computer systems on the NHS because, as I understand
it, any system will be capable of outputting in XML. Mapping one set of tagged
data to another can be easily achieved.
However, whilst XML offers huge potential benefit in the development
of EPRs and EHRs, it also has the potential to
waste huge amounts of time through each Trust re-defining schemas and templates
and style sheets. It would be very narrow minded of them to think that all
their tags and schemas should be different to anyone else’s.
What we must do now is to establish a process where we can share the
development work and structures for specific documents.
XML in healthcare: the potential
Electronic Patient Records (EPR)
The 6 levels of EPR in
acute hospitals require clinical systems to be built and integrated in an
incremental way. This can be perceived as the “active” EPR – the active systems that
support clinicians in real time with tools – order communications, electronic
prescribing, etc.The outputs from those disparate systems, i.e. the reports
or data that are published from those linked systems, could be standardised
in XML.
This may seem a daunting task but whilst added value will be derived
from developing specific schemas for every known report or document, this
too can be done incrementally and initially only a handful of documents need
be defined. The rest could initially be output as text without the structure.
Not ideal, but not a bad place to start. This repository or Passive EPR will be the legal record –read
only and browsable by clinicians from other hospitals or sectors.
Electronic Health Record (EHR)
In Information for Health, a concept of a patient’s birth to death
record is outlined, containing core clinical data and summaries from the organisational
(e.g. hospital) EPRs.
Those clinical staff with correct access rights, could be directed to
the repository or passive organisational EPRs (XML) described above, from
these summary EHRs.
There is a considerable work to be done to make this simplistic vision
a reality. There other options, and it is anticipated that the ERDIP
will be identifying these and other associated issues over the next two years.
Guidelines/knowledge
A simple search on the Internet reveals the real problem of information
overload.
A search for something simple, like back pain offers “the first
10 of 98,483 hits!”.
Heart Attack will provides 179,391.
A search for EPR offers
29,444 hits -some of which are about Electron Paramagnetic Resonance, and
one “hit” which identified the EPR Paradox. This paradox isn’t
about which system to buy but is the result of a thought experiment undertaken
by Albert Einstein and his colleagues demonstrating a lack of completeness
in quantum medicine! There’s even an Electronic Poetry Review! That
is the problem.
If we are to use the power of technology in getting up to date information
to the right people at the right place and at the right time, we need a system
of structuring such knowledge. We need to reduce the number of “hits”
in a search – reducing ambiguity. The National Electronic Library for
Health is actively pursuing these options e.g. through their support to the
Pathfinder work coordinated by Wirral Hospitals NHS Trust
GP to GP record transfer
Whilst this paper had focussed, in the main, on secondary care computing,
there has also been considerable work done on the transfer of a GP records
electronically to other GPs using an XML schema based on the CEN standard.
Patients changing GPs happens more than you would think, and the transfer
of their records efficiently is critical in the provision of continuity of
care.
Work undertaken in this area has been reported in the excellent Electronic
Patient Record Scoping Study (Scope EPR
report)
Communications/messaging
Many sites in the UK are looking at using the potential of XML to satisfy
their communication needs. Work is underway in the UK on discharge and referral
letters, interchange of pathology reports and on the requesting of pathology
tests etc. These sites are aware of the potential danger of “re-inventing
the wheel” when undertaking work in this area and there is an increasing
demand, from the NHS, to have a forum to share such developments and to reduce
unnecessary duplication of effort.
Conclusions
XML offers great opportunities in developing the Electronic Patient
and Health Records. It offers tools to make the access to knowledge more efficient
and less ambiguous and time consuming It also provides a means to share and
communicate clinical information in an effective manner. However, it does
not replace the traditional computer systems. It compliments them. There will
be an increased need for agreement on structure and codes in addition to the
structure provided by XML. The clinical headings work and the Snomed Clinical
Terms will continue to be essential contributors to this exciting new technology
which has the potential to change the way we work and live.
The views expressed in this paper are personal and do not
necessarily represent those of the NHS Executive or the Scottish Executive.