XML for electronic clinical communications in Scotland

https://doi.org/10.1016/S1386-5056(01)00199-XGet rights and content

Abstract

This paper describes the use of extensible markup language (XML) for electronic clinical communications in Scotland. It gives the results of the first UK project to send and receive discharge letters using XML. This pilot had the advantage of transferring readable clinical information between computer systems and giving the receiving GP choice of decoding and saving clinical and administrative data into his practice system. A number of existing clinical systems and a variety of written documents were studied. Existing trial standards, including the NHS EDIFACT, HL7v2 and CEN standard ENV 13606 were taken into consideration. The project worked with the receiving GP system supplier, GPASS, and the NHS Scotland Information and Statistics Division in defining the document type definition (DTD) for the pilot DTD. GPASS undertook production of a module for their system to parse the XML messages into the patient record on the GP system. The system allows the GP to read and print the original document and modify the content prior to storing in the practice system. SMTP e-mail messages were used for the pilot. Resulting messages were parsed into the GP system and validated by a variety of GP users. Currently there is a large scale program to develop XML Schema and web browser based communications of referrals, discharge and laboratory orders and reports.

Introduction

Referral letters are sent from GP to hospital consultant. Discharge letters are typically used to inform a patient's GP of the results of a hospital attendance principally for a hospital stay involving some form of procedure. The GP is interested in many aspects of the letter, not least medications which the patient may be taking, but also procedures performed and whether the hospital expects the GP to follow up the case. Hospitals use referral and discharge letters for several purposes, including case note summaries, and contracting, so they may contain more information than the GP requires. The format of discharge letters varies to some extent even within one hospital, but usually conforming to the Scottish Intercollegiate Guideline Standard.

Some pilot projects have undertaken centralising and automating the process of discharge letter production. One such project at Stobhill Hospital contributed to this pilot project. The NHS has a target of sending clinical messages between hospitals and GP's by electronic means by 2002 [1].

Within Scotland the Scotland Intercollegiate Guideline Network has undertaken the task of establishing national guidelines for a variety of practices and documentation. One of these guidelines is for immediate discharge letters [2]. Another is for referral letters. They dictate the minimum content and layout for such letters. The SIGN guidelines have broad agreement across Scotland being produced from within the industry.

The advent of the Internet spawned a number of projects sending discharge letters by e-mail or browser. The format of these was usually in a plain text or word-processor document format. Wide acceptance of this was not likely due to concerns about security. The progression of NHS net as a secure private network means that patient data travelling from hospital to GP by e-mail is more acceptable, as is web browsing with encryption.

Transfer of a referral or discharge document by plain text merely reduces the delivery time and increases legibility to the recipient. Traditional EDI messaging using formats such as EDIFACT transfer data between system without any human interaction. Trial EDIFACT messages for discharge letters were undertaken in UK in 1995 [3]. One problem was the wide variety of letter content and layout leading to problems of misunderstanding the context of information. The GP receiver requires to see and read the letter content before accepting all or parts of the data into his system. EDIFACT messages have gained acceptance for laboratory results in NHS UK. HL7v2 discharge messages only contain administrative fields.

Extensible markup language (XML) is derived from standardised generalised markup language (SGML) [4] and is useful for both display of data (e.g. a web browser) and also EDI messaging between systems. It has been used in both arenas successfully. It has advantages in messaging in that it is relatively quick and easy to implement. A disadvantage is that agreed content formats are required (called document type definitions (DTD) or Schemas).

Many businesses are creating de-facto standard schemas via workshops or industry agreements. Some industries have established entire languages using XML (e.g. chemical markup language [5]). The EU ISIS funded XML-EDI project is exploring the use of XML in many industries and helping to establish DTD's and schema. One arm of this has been a pilot to demonstrate GP–GP patient record transfer using a draft CEN standard message format [6]. HL7 v2 messages have been translated into XML format, future v3 messages are likely to be exclusively in XML. BDT messages used in Germany for clinical messaging are being translated into XML format. The Scottish Healthcare XML Project has the advantage of transferring readable clinical information between computer systems and also giving the receiving GP or consultant choice of decoding and saving clinical and administrative data into his practice or hospital system.

Section snippets

Methods

The immediate discharge pilot project started in mid-1998. The design of the first DTD was built around the established standard for XML version 1.0 [7] and for the pilot a decision was taken to avoid the many enhancements and extensions (including schema) put forward by various manufacturers during 1999. The SIGN guideline for immediate discharge [2] was used as a pre-requisite for the DTD.

A number of existing discharge letter systems and a variety of written letters were studied. Existing

Validation

In the pilot project a number of GP's in the area were matched against the GPASS list of users with the required version of their system. These were contacted and then self selected. They attended a briefing day and demonstration of the systems.

Care was taken to avoid sending real patient information. SMTP e-mail messages were used as well as X400 because of technical problems implementing X400 in all sites.

Practice staff were able to associate letters with the relevant patient properly. When

Conclusions

The results of this project proved to us that XML should be used for clinical communications. It is ideally suited to the rapid formation of local agreements on schema design and to the rapid implementation within healthcare systems. The results of this and other pilots in XML messaging are now being put into practice as the NHS in Scotland has embarked on a program of implementing electronic clinical communications using XML [10].

The NHS strategy calls for electronic clinical messaging to be

References (10)

  • F. Burns, Information for Health, NHS Executive...
  • Scottish Intercollegiate Guideline Network, Interface between the hospital and community, the immediate discharge...
  • NHS Executive, Data Interchange Standards Programme The Version 1 Trial NHS Standard EDIFACT messages for...
  • M.H. Aviram, XML for dummies, a quick reference. ISBN 0 7645 0383 9, IDG,...
  • St. Laurent et al.

    Inside XML DTDs: Scientific and Technical

    (1999)
There are more references available in the full text version of this article.

Cited by (24)

  • XML knowledge database of MRI-derived eye models

    2004, Computer Methods and Programs in Biomedicine
View all citing articles on Scopus
View full text