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Designing XML based medical applications for windows

Boumphrey, Frank
 
 Frank  Boumphrey
 M.D. FACS.
 Vice President
 Chagrin Falls
HTML Writers Guild
 Ohio 
 USA 
HTML Writers Guild,  15339 Hemlock Pt. Rd.
Chagrin Falls  Ohio  44022 USA email: frank@hwg.org
 Biography
 Frank Boumphrey - Frank Boumphrey is a retired professor of surgery who now specializes in Internet Applications and medical documentation.
 Abstract
 The changes in the US medical scene have left in place legacy electronic binary medical records systems that are unable to communicate with each other.
 This paper examines how XML and Visual Basic can be used to build Windows and intranet applications that enable these systems to communicate. Emphasis is placed on an incremental deployment of these systems.
 The widespread deployment of PC's running Windows means that any XML based system should be deployed on these platforms. The predominance of VB programmers, and the simplicity of using the MSXML ActiveX object dictate the use of these systems.
 Three case histories where this combination are used are examined.
 

The changing health care scene in the United States

 The health care scene in the United States today is unrecognizable from what it was 10 years ago. Cleveland, Ohio is typical example of how the scene has changed.
 Ten years ago the majority of medical practitioners were in private or small group practice, operating out of community hospitals and referring complex cases to tertiary care centers.
 Medical records were for the most part paper based, parochial, and reflected the whims of local providers. Communication between provider nodes in this system was invariably done using 'referral letters'
 Under the pressure of diminished reimbursement from insurance providers, and pressure from the Federal Government, this system has imploded.
 Today the original Tertiary care providers have reinvented themselves as Hospital systems, and now employ or manage between them 90% of the Doctors, and all the hospitals. They have also built several outpatient clinics to service the local population.
 These providers have attempted to impose a universal electronic records based system on their satellites, but for the most part all they have succeeded in doing is impose an additional layer of complexity on top of the old systems.
 The reasons for this include
 
  1. The pre-existence of proprietary binary electronic record systems.
  2. The difficulty of converting paper to electronic systems.
  3. The innate conservatism of medical practitioners.
  4. The length of time necessary to deploy new systems.
  5. High initial system costs which lock provider nodes to a single vendor.
 

The promise of XML and VB

 XML promises a means of providing flexible, incremental employment of electronic systems, and also provides a means for easy communication between disparate binary electronic systems.
 The one thing all medical systems have in common is that they all(99%) run Windows on PC's. Most of the medical programmers are versed in VB (80%+ use this language as their language of choice. Nation wide the proportion of VB:Java programmers is approximately 10:1), Foxpro, or C++. It is thus natural that any system deploying XML should leverage these existing conditions.
 The existence of the MSXML and more recently the MSXML II ActiveX object's make integration of XML and data bases an almost trivial exercise for the VB programmer using Visual Studio.
 Ultimately and ideally the whole record system will be based on a non-proprietary mark-up language (XML), but till that day comes XML can still be useful and used as an incremental replacement for existing systems. The following are case histories demonstrate some of the current uses.
 

Case studies

 

Creation of and management of new records

 PrimaHealth International is an organization concerned with the exchange of medical information across International boundaries. Typically a potential patient or their doctor will provide information of the patients medical condition, and this information is then used to match the patient with a suitable treatment center. Tenders and cost estimates for care are solicited from several participating centers in several countries.
 This process has recently been moved over from a traditional to a web/XML based system. Typically the client will fill out an HTML based form which is used to automatically generate an XML file. Triage personnel are automatically advised (email) of the receipt of a new file, and can immediately evaluate it. Reports can be forwarded to participating specialists, and in most cases a treatment plan can be generated with in 24 hours of the receipt of the initial information. Once approval of a treatment plan has been received from the client tender documents are generated from the XML files, and quotes are usually received within a week. Typically the only bottle neck tends to be getting exit and entry visa's for the patient.
 ASP and VB is used extensively throughout the whole process to access and manipulate the XML files. This automation has allowed the whole process to be reduced from several weeks to a few days.
 As a further benefit PrimaHealth is able to get many of the tests carried out in the clients locality, and indeed in many cases a costly trip overseas has been prevented.
 

Tracking blood test results

 With automation and centralization of blood analysis, the cost of actual analysis has been reduced to a few cents rather than several dollars. However the cost of processing, tracking, and documenting a test has continued to climb, and now constitutes 95+% of the cost of the test.
 Traditionally the following steps were employed in a simple blood test.
 
  1. Patient visits doctor
  2. Test is ordered (paperwork)
  3. Patient goes to phlebotomy area (paperwork)
  4. Blood is drawn and placed in container (paperwork)
  5. Blood is sent to lab (paperwork)
  6. Blood is analyzed, and result recorded (paperwork)
  7. Result is sent to Doctors office (paperwork)
  8. Result is triaged (human Intervention)
  9. Patient visits Doctor for report.
 In many cases the result had to be tracked down. This usually involved sleuthing skills and several phone calls. A recent study showed the average time taken to track down a delinquent record was about half an hour! Often it appeared that the patient had never even gone for the test.
 An XML/VB based system has simplified the system considerably. Now all the paper work is automatically generated from the original order entry, and an Intranet allows automatic tracking of the results. Further more simple programs allow automatic triage of the result, communication between provider nodes using different electronic systems, and in the many cases the follow up visit can be aborted.
 

Using XML based patient record files as pointer files

 Most proposals for paperless systems suggest moving all the patients file over to a complete XML based system. This however does not take into account the innate conservatism of medical practitioners, and under estimates the amount of angst involved in the process.
 A compromise system creates an XML based record that provides pointers to existing records, and allows the practitioners to continue making hand written notes etc. Further more the XML based system can point to other electronic sources, and provide links and a pointer to a broker to allow interpretation and presentation of these records. Letters stored in Word or WordPerfect are a trivial example, X-ray records stored in a binary format are a slightly more complex example.
 With decreasing storage costs several centers are experimenting with scanning hand written notes in Fax quality, and storing these for instant access. Although OCR is advancing to the point where it can read ordinary handwriting, it is doubtful it will ever be sophisticated enough to read doctors handwriting!
 

Conclusions

 There is no doubt that the universal acceptance of XML is a boon to the dissemination of medical information. However implementation of XML based systems runs into obstacles often of a political nature. Implementation to be successful has to work with existing systems, and just as importantly has to overcome the innate conservatism of the medical professions.
 This paper shows how XML systems can be successfully implemented by working with the existing Windows based systems already in place in most medical institutions. this eases transition and reduces the angst of all involved.
 Acknowledgements
 The author would like to thank PrimaHealth International (http://www.primahealth.net) for allowing him to use their applications and material in this paper.
Using XML for flexible data entry in healthcare   Table of contents   Indexes   XML in healthcare computing