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XML for discharge summaries, clinical coding & bronchoscopy reports

 XML in use in healthcare
Chamberlain, Mansel
 
 Mansel  Chamberlain
 Business Systems Manager
 Chelsea
London
The Royal Brompton & Harefield NHS Trust
 United Kingdom 
The Royal Brompton & Harefield NHS Trust,  Sydney Street
Chelsea  London  SW3 6NP United Kingdom
Phone: +44 (0) 171 351 8744 Fax: +44 (0) 171 351 8781 email: m.chamberlain@rbh.nthames.nhs.uk web site: www.rbh.nthames.nhs.uk
 Biography
 Mansel Chamberlain - Responsible for implementing clinical systems across the organization and delivering the Electronic Patient Record for the Trust.
 Abstract
 The Royal Brompton Hospital needed to update systems for clinical coding, the production of discharge summary letters and bronchoscopy reporting. The Trust considered several web-based solutions but chose an XML based solution from Graphnet; this enabled a fast implementation, whilst also recognising the longer-term benefits of an XML based solution. The benefits were the ability to capture and analyse clinical information, something that had never been possible before. This has major implications for research activity and clinical governance, both areas of critical importance in developing healthcare in the UK.
 

Introduction

 Royal Brompton Hospital NHS Trust and Harefield Hospital NHS Trust merged on 1 April 1998 to form a new NHS Trust - Royal Brompton and Harefield NHS Trust. This is the largest cardiothoracic centre in the UK and probably the largest in Europe. The Trust is at the leading edge nationally and internationally in the investigation, treatment and care of people with heart and lung disease.
 The Trust’s mission is to be the leading national and international centre for the diagnosis, treatment and care of patients with heart and lung disease, creating and disseminating knowledge through research and education.
 The Royal Brompton Hospital had an existing system for producing discharge summary letters and attaching clinical codes for procedures and diagnoses to episodes of care for in-patients and outpatients. This system was not Y2K compliant and the initial plan was to upgrade the existing system to make it compliant, however, it became apparent that this would not be possible for several reasons. Customisation and modifications to the existing system had, over time produced a complex system to maintain let alone modify. Analysis showed the major reason for these additions was that the existing system had a link to the main hospital administrative system, and by using this link, it was possible to import the demographic data for patients. This was sensible but the system required considerable manual intervention to manage and medical secretaries did not like the in-built word processor, as it was somewhat dated and not as easy to use as the word processing systems used for the rest of their work.
 

Requirements

 The simple solution would have been to upgrade or buy another package, but this would not have dealt with the fundamental issues that needed resolution, these were to:
 
  1. Allow clinical coding staff to add codes for procedures and diagnoses for episodes of care quickly and easily.
  2. Introduce a system to produce discharge summary letters quickly and easily.
  3. Install a system for the production of bronchoscopy reports.
  4. Give coding and other staff the ability to link patients to research studies and produce costings for research studies.
  5. Install a system to feed the hospital Electronic Patient Record (EPR).
  6. Gather information entered as free text in a manner that allowed subsequent searching and analysis.
  7. Provide a facility to communicate with referring physicians and GPs electronically was paramount, as the hospital is a major tertiary centre and receives patients from all over UK.
  8. Give referrers and GPs on-line access to the hospital systems through a browser solution, it was envisaged that this would enable referrers across the country to access the hospital systems;
  9. Install a system that would assist the Trust to improve Clinical Governance.
 This was a tough agenda and time was running out with 2000 approaching. The IS Department had carried out a wide-ranging survey of the systems available and had eventually settled on Graphnet as the company with the solutions to meet the requirements. The Graphnet solution was XML based. Whilst no standards for XML had been agreed the potential for XML was clear, and if the links with the wide range of other referrers and GPs were to be established XML offered an expandable and cost effective solution.
 A survey of the medical secretaries and coders confirmed the complexities of the issues to be resolved. An important principle agreed at the outset was that where possible no changes to existing working practices would occur. This was important to gain user acceptance for the changes.
 

Implementation

 A small project team consisting of users, IT staff Graphnet and managers met very regularly to agree content, test initial ideas, modify ideas and produce the pilot. This pilot was demonstrated to all users; modifications were based on further feedback.
 A detailed analysis of discharge summary letters was carried out to establish the current pattern and structure of the letters. This was a vital part of the project as this exercise was fundamental to the construction of the XML schema and the subsequent analysis of the data. Medical staff had complete freedom in how they produced summaries. Quality was variable and in many cases, secretaries had developed templates into which they slotted the information provided by medical staff on tape. To gain acceptance for a standard structure was almost impossible, so the project team had to make decisions based on acceptance from as many users as possible. The difficulty of this task cannot be overestimated and admit that full acceptance has yet to be achieved. The delivery of an analysis module is the key to acceptance; once senior medical managers understand the benefits of searching an analysing what is essentially free text, and the potential for clinical governance become apparent then the issue of form and style within documents will be appreciate and resolved.
 The system for dealing with Bronchoscopy needed simplification and clarification. This was an administrative rather than technical issue related to the ways in which the administrative systems dealt with patient admissions for day-care. Essentially, the system records the results of tests performed on patients.
 In December 1999, the first modules were delivered and the project went live.
 

Coding module

 The coding module enables the clinical coding staff in the hospital to identify episodes of care fed from the main hospital administrative systems and attach Diagnosis codes (ICD) and Procedure Codes (OPCS) to episodes, during and after a patient is admitted to hospital.
 

Discharge summaries module

 The secretaries’ module links to the coding module; secretaries cannot complete a discharge letter until coding is complete. Multiple episodes can be linked to produce one discharge letter for the referring physician; the system also enables secretaries to export documents to Microsoft Word for further enhancement if necessary.
 

Bronchoscopy module

 The bronchoscopy module allows medical. Nursing or administrative staff to enter the results of tests including simple diagrams and forward this information to the GP or referrer in the same way as a discharge letter.
 

Delivery

 Within eight weeks a working system was installed, this needed some modification but the basic structure was correct. There has been the inevitable period of consolidation and modification during the first quarter of 2000. However, the Hospital now has a repository of searchable, analysable clinical information. This information had previously been analysed manually. The potential for research is enormous in a number of ways, e.g., one of the most difficult areas of research is to assemble an acceptable set of patients to form the basis for the research or trial. Whilst this system will not help with all studies, the ability to search through a series of free text documents and identify patients who meet complex criteria that my range from the usual demographic criteria, age, sex, through disease, drug therapy or surgical procedure to outcomes. The same is possible for clinical governance where the issues are similar although the search requirements may well be equally complex.
 

Other issues

 The need to convert legacy data to XML format was paramount and the old discharge summary system contained over 300,000 episodes. Graphnet produced a solution that converted 98% of these old records into XML format. This immediately produced a wealth of data available for analysis.
 

Clinic, ward and operation notes

 No formal procedures existed within the hospital for gathering the data from clinic notes, ward notes or operation notes. Many of these documents were produced on computers, but the final documents were printed and inserted in the patient notes. The electronic version remained on a local drive. These notes are an important part of the patient record.
 Most patients will return to the hospital for a number of visits initially monthly and then three, six and twelve monthly, before final discharge. The ability to refer to the last clinic note easily, as part of an electronic patient record, is an obvious benefit and long overdue. The time saving is immense as the doctor can refer quickly and easily to what happened at the last visit and when dictating the note of the current visit does not need to repeat diagnoses, treatment, etc., these can be carried forward by a secretary and repeated. Operation, clinic or ward notes can now be incorporated into discharge summaries saving time and providing a better service to referring doctors and GPs.
 

Other developments

 The potential of XML is such that we decided to convert another system to incorporate XML. The hospital runs an Occupational Medicine Department where the effects of particular working environments are measured. This was an ideal candidate for XML as the requirements for interrogation and research were unclear and the need was for extreme flexibility in searching and analysing data, along with the basic requirement to enter text easily and quickly and to generate flexible visual reports.
 

Conclusions

 The hospital now has a wealth of data stored in XML format, all this information was gathered electronically, but was stored in disparate systems across the Trust. All the information is now available to form part of the electronic record now being implemented within the Trust. A major benefit of the system is the repository of searchable data that is now available. The fact that this information is essentially free text, gathered as part of the administrative process of running the hospital is a major additional benefit.
 There is considerable work to be done but solutions now exist that enable the original objectives to be realised. To recap these objectives were:
 
  • The need to allow clinical coding staff to add codes for procedures and diagnoses for episodes of care quickly and easily.
    •  
  • To introduce a system to produce discharge summary letters quickly and easily.
    •  
  • To install a system for the production of bronchoscopy reports.
    •  
  • Give coding and other staff the ability to link patients to research studies and produce costings for research studies.
    •  
  • To install a system to feed the hospital Electronic Patient Record (EPR).
    •  
  • To gather information entered as free text in a manner that allowed subsequent searching and analysis.
    •  
  • To provide a facility to communicate with referring physicians and GPs electronically as the hospital is a major tertiary centre and receives patients from all over the UK.
    •  
  • To give referrers and GPs on-line access to the hospital systems through a browser solution.
    •  
  • To install a system that would assist the Trust to improve clinical governance.
    •  

    The future

     The potential for XML in healthcare is immense. There is a desperate need for standard descriptions and DTDs. There seem to be many groups talking about standards but little action. I hope that there will be some rapid progress in resolving this fundamental issue.
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