Designing XML based medical applications for windows   Table of contents   Indexes   XML for blood ordering, investigation ordering and lab results
 

XML in healthcare computing

 the potential
 Brennan, Sean 
 
 Sean  Brennan
 Independent consultant in healthcare computing
  Leeds 
NHS Information Policy Unit
 United Kingdom 
Yorks
NHS Information Policy Unit,  Department of Health
Quarry House
Leeds  Yorks  LS2 7UE United Kingdom
Phone: Phone: +44 113 254 6247 Fax: Fax:+44 113 254 6261 email: seanbrennan2@compuserve.com
 Biography
 Sean Brennan - Initially a Chief Medical Laboratory Scientific Officer in Immunology, then medical audit co-ordinator and Trust Information Manager, Sean's career reflected his personal objective "to link the application of IT to the "improving clinical care" agenda". Sean was appointed clinical audit advisor to the Department of Health in 1995. As Electronic Patient Record Project Manager for the NHS in England from 1996 - 1998, he was responsible for supporting a number of innovative and ground-breaking SGML projects at Oswestry Hospital, which had been proposed, with great foresight, by an orthopaedic surgeon, Mr Andrew Roberts. Since 1998 his time and duties have been split between the Health Department of the Scottish Executive, the NHS Information Policy Unit in England and independent consultancy projects. One such project was an invitation to Shanghai, along with two colleagues, to contribute to the development of the Shanghai Municipal Health Board's IM&T strategy. He believes that EPR (reinforced by the NHS's Information strategy "Information for Health") should be focused on supporting the clinical care processes with IT and not simply about creating a record on computer. And any record so formed, if XML based, will offer far more to clinicians and managers than traditional database paradigms.
 In 1995, Sean Brennan, Bill Dodd and Peter Drury introduced the NHS to the concept of using markup language (SGML ) for clinical information. Sean Brennan is an independent healthcare consultant His considerable experience of practical clinical computing includes three years as NHSEPR Programme Manager. He is presently working with the NHS Policy Unit and the Scottish NHS Executive advising on a wide range of clinical computing issues.
 Abstract
 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?
 

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.
 

Information for Health

 Information for Health outlined the strategy for developing IT in the NHS over the next 5 years (2005).
 EPR, Electronic Patient Record 
 		One of the main objectives of the strategy was to develop anEPR in every Trust.
 EPR, Electronic Patient Record 
 		At this stage let me clarify how the acronymEPR is used in this context. TheEPR 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.
 EPR, Electronic Patient Record 
 		TheEPR (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.
 EHRs, electronic health records 
EPRs
 		However, whilst XML offers huge potential benefit in the development ofEPRs andEHRs , 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)

 EPR, Electronic Patient Record 
 		The 6 levels ofEPR 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.
 EPR, Electronic Patient Record 
 		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 PassiveEPR will be the legal record –read only and browsable by clinicians from other hospitals or sectors.
 

Electronic Health Record (EHR)

 EPR, Electronic Patient Record 
 		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)EPR s.
 EHRs, electronic health records 
 		Those clinical staff with correct access rights, could be directed to the repository or passive organisational EPRs (XML) described above, from these summaryEHRs .
ERDIP, Electronic Record Development and Implementation Programme
 		There is a considerable work to be done to make this simplistic vision a reality. There other options, and it is anticipated that theERDIP 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.
 EPR, Electronic Patient Record 
 		A search forEPR 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 theCEN 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.
 EPR, Electronic Patient Record 
 		Work undertaken in this area has been reported in the excellent Electronic Patient Record Scoping Study (ScopeEPR 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.
Designing XML based medical applications for windows   Table of contents   Indexes   XML for blood ordering, investigation ordering and lab results