Using XML to Bridge the GP Hospital Divide

1. The Situation

The Path.Finder project began as a local initiative at Wirral Hospital NHS Trust in 1994, with the Trust initially providing guidelines for GP's on topics in which they had expressed an interest. A hypertext package running on laptops was used to structure and display information, and the system was piloted with 25 GP's. Most of them found the system very valuable, improving their clinical practice and the way they referred patients. The Trust then decided to roll out the system to other GP's and began to develop further books for use within the Trust. These were made available on standalone PC's in around a dozen wards. The Trust also joined forces with a number of other Trusts in 1996 to create a Consortium to develop and promote the Path.Finder system.

The first incarnation of Path.Finder provided significant benefits to both clinicians and patients. However as the scope of the application grew, software constraints became apparent. These tended around document management issues, interoperability, licensing and basic table and image support. XML offered a way around these constraints by supporting complex images and digital photography, an important aspect of medical information tools. It also allowed tables and links to external applications. The two major benefits though were the automation of the maintenance of the guidelines, and the ability to interact with existing systems. The Wirral database alone contains 3500 pages of information, and with previous systems it was nearly impossible to keep track of which pages had passed their expiry date and to make sure that the authors reviewed them, the move to XML has solved that problem.

As the GP community and the staff at the Trust became more positive about all aspects of information technology the requirement for the system to be able to link into existing legacy systems such as the hospital PAS became more and more apparent. In addition local care workers and specialist nursing staff who work remotely, often in a patients home also realised the benefits of being able to access reliable information promptly, but needed access without having to connect directly to the database. It was and is this continuous demand for greater functionality which has driven the project forward.

2. The Solution

To provide it with the expertise to kick start the project, Wirral decided to work with an external consultancy called Graphnet. As the staff that worked on the system were mostly trained to be able to use office suite applications a major worry on the part of the IT departments was the apparent complexity of coding in XML. Therefore a key element of the solution was an interface that would allow users with these basic skills to create and manipulate XML documents. Graphnet used Visual Basic and C to develop a publishing tool that allows users to enter text directly or to draw on existing word processing files. All data is saved on a SQL database.

The flexibility of XML allows Wirral to deliver Path.Finder on a number of platforms including over the NHSnet to standalone PC's running older web browsers and on touchscreen patient information kiosks which have been deployed around the Trust. The XML version of Path.Finder is available on more than 300 PC's around the hospital, and via a second server held at the local health authority which mirrors the content of the Trust based server, each GP in the locality can access the system from their desk.

Access is also provided to remote working staff using laptops with the database preloaded but running a server to allow effective searching to be carried out. This solution is not perfect but other possibilities are currently being examined.

3. The Benefits

Xml has allowed Wirral to solve the issues it faced with the Non-Web compliant version of Path.Finder. Guidelines can be managed and maintained more easily, while new data types such as digital images can be incorporated. In addition, the widespread availability of the webbrowser interface means Path.Finder can be rolled out to a much wider community of users.

Using XMl has brought other benefits as well. For example, because Path.Finder data is now stored in a database rather than as pre-constructed pages containing metatags, users can perform more powerful searches and link directly to relevant paragraphs. Also because XML sends only unformatted data, access times for staff working remotely are comparable to staff using a locally stored proprietry system.

Relevance and currency of information are the most important aspects of systems such as these. Again using a server based technology has allowed us to improve these aspects. Updating of standalone systems is a time consuming and costly business running the system from a server has meant we can eliminate the majority of these problems are no longer an issue. Ward staff who rely heavily on the information and are regularly distributing it to patients can be assured that any necessary changes to information are made within two working days of the department being informed.

4. The Future

The Path.Finder project represents just the first step in Wirral's plans for XML. Because XML is inherently compatable with database technology, the Trust is now providing referral forms online. These forms have initially been coded in HTML for evaluation but it is hoped, they will be converted using XForm to allow patient data to be sent directly to a referral database at the Hospital

In addition the Trust is beginning to develop EPRs using XML, the structure provided by XML will allow Wirral to link patient and Path.Finder records together. For example a clinician will be able to use the clinical codes for the diagnosis in the patient record to jump to the relevant clinical guidelines for that condition in Path.Finder. Some work has already been done allowing XML discharge summaries to be created from the PAS system which are accessible by the GP.

Addressing the problems of portability, the Trust has started using PDAs running the Pocket PC platform on a wireless network as thin clients in areas such as A&E. Being a Teaching Hospital this means that the junior members of staff can access a fully searchable dataset on the move, the next step is to provide access to the PAS system in this way to the general management of the patient. Over this coming year the important step in this aspect of the project is to try to provide an Avantgo style service to allow the users to access a fully mobile service.

Other projects now being planned include the delivery of education modules which will allow staff to test their knowledge in around 50 clinical areas with the ability to make greater use of guidelines developed by other healthcare providers. Interoperability with GP systems, many of whom are moving to an XML platform, we are working with system provider EMIS, who have provided access to their DTDs to facilitate the automatic generation of patient demographics into forms which are based on our own system. We are also working closely with a groupn of GPs in the local area, who are providing content for the system. This will allow a true exchange of information, with hospital staff able to access information on which practices provide which services, and giving the GPs full access to hospital information, the hope is that we will facilitate a truly seamless system for patient care.

Design and Development by deepX Ltd.