Electronic Health Information Standard based on CDA for Thai Medical System: focused on Medical Procedures in Medium-sized Hospitals (HOSxP)

Transcription

1 th International Joint Conference on Computer Science and Software Engineering (JCSSE) Electronic Health Information Standard based on CDA for Thai Medical System: focused on Medical Procedures in Medium-sized Hospitals (HOSxP) Napat Sarutiyapithorn, Nutrugee Wisawanart, Mutita Saowaneepitak, Worapan Kusakunniran, and Kittikhun Thongkanchorn Faculty of Information and Communication Technology, Mahidol University, Thailand Abstract Electronic health information standards have been developed in several countries, which are in different formats. The Clinical Document Architecture (CDA) is the most acceptable and widely used. In addition, Hospital and Experience (HOSxP) is a Healthcare Information System (HIS) developed by Bangkok Medical Software (BMS), which is currently deployed by medium-sized hospitals in Thailand. However, different hospitals may use different HISs. For example, many small-sized hospitals use Java Health Center Information System (JHCIS). Thus, electronic medical information transfer is not trivial. Currently, in Thailand, the patient transferring process relies on a paper work. Therefore, this paper is to propose electronic health information standard based on CDA, which is in an Extensible Markup Language (XML) format, focused on medical procedures using HOSxP system. This work consists of three main developing phases: 1) data mapping, 2) data exporting, 3) data importing. First, data recorded in the HOSxP database is mapped to data required by the corresponding CDA, which will be slightly adjusted to suit Thai medical information. Second, data recorded in the database is extracted and exported into the CDA based standard, which will be transferred to another (i.e. destination) hospital for the patient transfer. Third, once the destination hospital receives the CDA based standard file, it needs to import the embedded patient information from the file into its database. Then, this transferred patient record can be used across the hospital as basis information for further treatment. Keywords electronic patient transfer; CDA; HOSxP; HIS; clinical document; medical record; healthcare information standard I. INTRODUCTION In Thailand, different hospitals may use different Health Information Systems (HISs) such as Hospital and Experience (HOSxP), Java Health Center Information System (JHCIS), Hospital OS, and Electronic Medical Record Software (EMR Soft) [1]. Therefore, when the patient transferring process is occurred between two hospitals which use different HISs, the information of the patient cannot be transferred straightforwardly in an electronic way. Currently, the transferring process is done by a paper work, which is quite slow and difficult and can often be incomplete. As shown in [2], it said that during the research time in 1994, there was 19.1% of the transferring case which the information was incomplete and also 13.4% that had no information at all. Moreover, the frightened fact showed that 91.8% did not have any communication before sending the patient to another hospital. Another problem is that the paper work is sometimes difficult to be handle. It can be difficult to deal with storage, loss, distribution, and editing [3]. Eventually, these drawbacks can lead to a discontinuity of treatment on a particular patient when he/she is transferred to another hospital. Another consequence from this difficulty is distribution of the patient [1]. There is an abundance of the patient in the bigger and well-equipment hospital, then there might be insufficient medical resources and could not support the new transferred patient. In order to overcome this problem, if the transferring process gets easier, then the patient can get the treatment or operation in the well-equipment hospital and then be transferred back to the smaller hospital which is close to his/her home for recovering or continues physical therapy. From the problems above, the one who has been affected most is the patient. The patients may lose a good opportunity in their treatment and not receive the fully efficient continues medical services when they are transferred between different hospitals. The Ministry of Health concerns of this situation in order to provide the best service to their people. Therefore, they come up with the policy to develop the transferring system to meet level of effectiveness [1]. Then, this paper aims to study and understand the electronic clinical document standard, which in this case is Clinical Document Architecture (CDA) [4] which has been developed by Health Level Seven International (HL7). In order to use this standard in Thailand, it is also important to map its contents to data recorded in HISs that are used in our country as well. For the scope of this paper, HOSxP is focused here, since HOSxP is used in most mediumsized government hospital. Then, a prototype of electronic clinical document standard for Thailand will be developed and implemented, which can replace the paper work for patient transfer process. The rest of this paper is organized as follows. Background is explained in section II. It reviews the literature and knowledge /15/$ IEEE 97

2 that have been mainly used in this paper. Framework is shown in section III. It describes roughly what will be done in this work. Implementation and results are described in section IV. Then, conclusions and limitations are drawn in section V. II. BACKGROUND A. Health Level Seven International (HL7) In exchanging the data, the standard is needed to create the functional and semantic interoperability between the healthcare providers, for example, the common data structures, common medical terminology, common information model, and common transport standard. There are two organizations which are able to create a standard document for exchanging the data components: 1) HL7 s CDA and 2) the American Society for Testing and Materials (ASTM International) s Continuity of Care Record (CCR) [5]. In this paper, HL7 is selected, since HL7 s CDA can support multiple purposes of data exchanges. Therefore, it can be used to exchange in many scenarios other than the transport of health summary, which is the only purpose of CCR. On the other hand, CDA is adaptability and extensibility [6]. HL7 is a non-profit organization established for providing a framework and standards in exchanging, integrating, sharing and retrieving the health information in the form of electronic document. The standard defines the way to transfer the information from one provider to another, also concerns with the packaging, the language, structure, and data type. The organization is one of an American National Standard Institute (ANSI). It is found in 1987 and now there are more than 2,300 members who serving in healthcare area [4]. It has developed the rules for communication that is widely used in the United States, together with expanding to the international recognition and implementation [7]. CDA is an architecture that HL7 has developed and been widely used. This will be described in detail in the sub-section. B. Clinical Document Architecture (CDA) CDA is a document markup standard specifying the structure and meaning of clinical documents. Its objectives are mainly to exchange between healthcare providers and patients. CDA can be used in many types of clinical content such as discharge summary, imaging report, admission and physical, and care record summary (CRS). In this paper, CRS is used as a case study. The CDA document can contain text, images, sounds, and other multimedia content. It has following characteristics: persistence, stewardship, potential for authentication, wholeness, and human readability. CDA has been employed in many countries where health information exchange (HIE) is well established, such as Finland, Greece and Germany [4]. It is also used in pilot HIEs in Canada, Japan, Korea, Mexico, and Argentina. Firmly, CDA is in the plans for the US Military Health System and many of the nascent US HIEs. The component of CDA is shown in Fig. 1 as a skeletal example. CDA document is covered by <ClinicalDocument> <ClinicalDocument>... CDA Header... <structuredbody> <section> <text>...</text> <observation>...</observation> <substanceadministration> <supply>...</supply> </substanceadministration> <observation> <externalobservation>... </externalobservation> </observation> </section> <section> <section>...</section> </section> </structuredbody> </ClinicalDocument> Fig. 1. CDA skeletal example element, and contains two main parts, which are header and body. The header is in between <ClinicalDocument> and <structurebody> elements. The header provides the classification of document and the information on the document (e.g. authentication, encounter, patient and involved providers). For the body, it contains the clinical report. It is wrapped by <structurebody> element, and consists of <section> element. Each section can contain a single narrative block, any number of CDA entries, and external references. The narrative block is used with <text> element and contains the human readable content. In <section>, the narrative block shows the content for rendered, meanwhile CDA entries represent the structured information in order to run further computer processing [8]. CDA is derived from HL7 Reference Information Model (RIM), which represents the form of clinical data, and determines the life cycle of the message. It has been approved by ANSI to be a shared model of all domains [4]. C. Care Record Summary (CRS) CRS document encloses patient s health information for a period of time. Its main purpose is to provide the standard format to transfer and report back to primary provider or other who interested in the information. This facilitates the communication between healthcare providers. Its benefits are to transfer discharge summary information as free text, image, or structured codec data, to provide a format for narrative notes and electronic health record (EHR) and to support important minimal changes to current practice [4, 9]. CRS is wrapped by <ClinicalDocument> element as CDA template and consists of header and body. The information that identifies the unique of the document is in the header part (e.g. typeid, templateid, id, code, and participants). There are many participants, which have to be included in this document, where a single person can be in several roles. For body, there is either a structuredbody or nonxmlbody element. This information is organized into sections and may consist of sub-sections. The nonxmlbody element contains either actual CDA contents or reference by URL. It should not contain both since it is generally bad practice. The structuredbody element is coded using Logical Observation 98

3 <recordtarget> <patientrole> <id extension='12345' root=' '/> <addr> <streetaddressline>17 Daws Rd.</streetAddressLine> <city>blue Bell</city> <state>ma</state> <postalcode>02368</postalcode> <country>usa</country> </addr> <telecom value='tel:(781) ' use='hp'/> <patient> <name> <prefix>mrs.</prefix> <given>ellen</given> <family>ross</family> </name> <administrativegendercode code='f' codesystem=' ' /> <birthtime value=' '/> </patient> <providerorganization> <id extension='m345' root=' '/> <name>good Health Clinic</name> <telecom value='tel:(999) ' use='wp'/> <addr> <streetaddressline>21 North Ave</streetAddressLine> <city>burlington</city> <state>ma</state> <postalcode>01803</postalcode> <country>usa</country> </addr> </providerorganization> </patientrole> </recordtarget> Fig. 2. The recordtarget example Identifiers Names and Codes (LONIC) [9]. LOINC is the universal standard for medical laboratory observations. It provides standard code name and identifiers to medical terminology which involved in EHR [10]. D. HOSxP Hospital and Experience (HOSxP) is a HIS, which consists of EHR. It is a popular open source HIS that has been used in medium-sized hospitals over 500 places in Thailand, for both government and private hospital. The program intends to make the healthcare workflow flows easier for small sanatoriums to central hospitals. It is developed in 1999 from the solo project of Chaiyaporn Suratemekul, a pharmacist, then developed further by main developer in Bangkok Medical Software Co., Ltd., a company led by Chaiyaporn. It is designed to use with relational database management system such as MySQL, Microsoft SQL Server, PostgreSQL, and Interbase/Firebird. The system can collect the image and fingerprint of the patient, including some drawing, which helps reducing paper work. It can export the information into many formats like EXCEL, DBASE, XML, or HTML. The authentication is supported by user id and password to access to the system. The program provides various functions up to 26 departments [11, 12]. E. 43 Folders If talking about clinical standard document, Thailand also has one. The Bureau of Policy and Strategy, Ministry of Public Health created the 43 folders standard. The folders contain the provided service information and the support of the prevention of the disease in individual (OP/PP Individual Record). The minimum data set is fixed to have 18 basic folders in 2009 and then is changed to 21 folders. However, these folders lack of some financial information and many of the folders were created long time ago, so they are not up-to-date with the present system. Next, 43 folders come. They are developed from 21 folders, which include financial information, provider information and other changes [13]. However, the use of this standard is mainly for collecting the data for statistic for Ministry of Public Health and also for disbursement from the government to each hospital. It is not specific for patient transferring process. III. PROPOSED FRAMEWORK In this paper, the proposed framework is clearly separated into three parts, in order to achieve our objectives as mentioned above. First, the data mapping process, it attempts to adjust CDA s contents to match with health information records in Thailand, especially in HOSxP s database. Since patient information and health records are sensitive and important, exact data mapping is required in this process. There are several main cases of the data mapping occurred here. For the data that appears in both CDA and HOSxP, having identical content and data type, direct mapping is immediately applied without any modification. For the data that appears in both CDA and HOSxP, but having different details and/or data type, the original CDA standard needs to be adjusted to suit with HOSxP by extending the standard, adding more XML information tags, and/or changing type of the data from HOSxP when mapped into the CDA. For the data that appears in HOSxP but not in CDA, if it is important for the patient transferring process or treatment, it needs to be added into the CDA standard as well. For the data that appears in CDA but not in HOSxP, it can be ignored if it is not related to Thai medical information. Otherwise, HOSxP should be extended or additional program should be created to collect this data from patients. Second, the data exporting process is to extract the data from local health information system, e.g. HOSxP s database, into the standard based on CDA which is in the XML document format. The standard-based exported file will be used in the patient transferring process. It can be transferred to other hospitals via the secure File Transfer Protocol (FTP) method for continues treatment of the patient. So, outcomes of the data mapping process are used to facilitate this data exporting process. The data in the HOSxP s database is retrieved and exported into the XML format, which each tag is served for one data content and its type. 99

4 Fig. 3. The proposed workflow diagram Third, the data importing process, once the destination hospital receives the CDA document in the patient transferring process from the source hospital, it will insert the data information from the received file into its local database. Converting the XML format into the database, the sql query process is required. Nevertheless, both data exporting and importing between different HISs (e.g. HOSxP and JHCIS) are required in both source and destination hospitals. Different HISs have different database structures. Thus, both systems have to follow the CDA format, which is the standard for information transfer, in exporting and importing processes. As shown in Fig. 3, the proposed workflow represents how the main processes mentioned above perform together. The system aims to transfer the medical information between medium-sized hospital and any other hospitals, which use any other HISs such as JHCIS. First, the HOSxP system is required to connect to its database and the exporting and importing adapter programs must be installed before the transferring can be started. Then, the requested patient information and/or medical information are retrieved from the HOSxP s database and extracted into the extended XML-based HL7-CDA document which is now ready to be transferred. On the other hand, when the HOSxP system receives the XML-based document of CDA, the importing adapter is then used to transfer the data from the CDA file into the HOSxP s database. IV. IMPLEMENTATION AND RESULTS Since the standard is based on HL7-CDA standard for storing clinical data, our main task is to be able to extract information from the health information system e.g. HOSxP to the CDA based standard. According to the matching table created in the data mapping process, the CDA files of patient information and health records are implemented to be used as a prototype for demonstrate the patient transferring process. The software, so-called adapter, is developed to link between the standard and the health information system s database. This software is developed using Java Development Kit (JDK) 1.7. In the process of exporting data, a class is first developed to handle xml file structure which being used for generating an Fig. 4. User interface for the data exporting xml standard or the CDA that have been mentioned. In this generated CDA, it contains patient information which is extracted directly from the database using the provided Java library for database connection, namely Java Database Connectivity (JDBC). The adapter software also provides connection management section to support external database server. In this process, the users are required to input either patient identification number (HN) or visit number (VN) to specify the record target as shown in Fig. 4. After the users enter such information, the adapter software will return a brief summary about the target to ensure the correctness. For the importing process, Document Object Model (DOM) is used to handle the incoming CDA standard file. Then, all elements under the same tag-section are grouped together, as most of them is extracted from the same table in the database. Some pieces of information stored in the standard are adjusted to sustain a universal sharing capability. Therefore, such data needs to be converted to match the type specified in the database. Fig. 5 shows the user interface for importing patient information. The overall layout is shown to be similar to the interface for exporting data. However, in the data importing process, the adapter software allows the user to locate the standard file s path which will be imported to the system s database. 100

5 enhances the continuous treatment of the patients when transferred to another hospital. So, the patients can save their money, time, and even life. In addition, this work also helps replacing the paper work used in the traditional patient transferring process with an electronic document, which consequentially helps in managing the data storage and organization. Since this work now focuses on HOSxP, then in the future work, other HISs e.g. JHCIS will be collaborated, to make the system to be broadly used and go further for the country-level standard. Another important aspect to be concerned is the security in the data transferring process. This will be considered in the future work for creating and transferring the CDA-based standard files in the secured way. Fig. 5. User interface for the data importing When combining the data exporting and data importing processes, it creates a system where data can be exchanged between different HISs, by communicating within the same CDA-based standard. In this work, the exporting and importing adapters are implemented to link between the CDA-based standard and the HOSxP system. Thus, two or more hospitals that use the HOSxP can communicate via this CDA-based standard. Since such standard is used as the medium in the communication for patient transferring process, other hospitals that use any other HISs can establish the link between their HISs and the standard, in order to be able to communicate to each other via this communication channel. V. CONCLUSION As described in this paper, the intermediate adapters for data exporting and importing processes are implemented to covert patient information and medical records between HIS s database and CDA-based standard. Then, the patient transferring process can be done fluently and easily throughout the system in an electronic and automatic way. Any HISs used in hospitals can communicate and exchange information via the CDA-based standard. This system can enhance the ability to transfer patient information between hospitals. The patient transferring process will be faster, easier, more comprehensive, and more effective. Once the transferring is easy to make, it will help distributing patients from the dense central hospitals to the other hospitals, or transferring patients from hospitals in rural areas to more equipped hospitals when needed. It also REFERENCES [1] M. Manotham, "EMS and referral management," [2] S. Jongwattana and W. Chadbunchachai, "Referal audit for international triage," Khon Kaen Medical Journal, vol. 20, May [3] T. B. Iversen, A. D. Landmark, and A. Tjora, "The peace of paper: patient lists as work tools," International Journal on Medical Information, vol. 84, pp , January [4] (20 Febuary 2015). Health Level Seven. Available from: [5] (03 March 2015). ASTM International. Available from: [6] J. M. Ferranti, R. C. Musser, K. Kawamoto, and W. E. Hammond, "The clinical document architecture and the continuity of care record: a critical analysis," Journal of the American Medical Informatics Association, vol. 13, pp , May [7] R. H. Dolin, L. Alschuler, C. Beebe, P. V. Biron, S. L. Boyer, D. Essin, et al., "The HL7 clinical document architecture," Journal of the American Medical Informatics Association, vol. 8, pp , November [8] M. Robert H. Dolin, L. Alschuler, B. Sandy Boyer, C. Beebe, P. Fred M. Behlen, P. V. Biron, et al. (2005, 04/03/2015). HL7 clinical document architecture, release 2.0. [9] L. Alschuler, C. Beebe, M. Robert H. Dolin, P. Fred M. Behlen, and K. W. Boone, "Implementation guide for CDA release 2 level 1 and 2 care record summary (US realm)," Health Level Seven International, June [10] W. contributors. (12 March 2015). LOINC. Available from: [11] W. contributors. (06 March 2015). HOSxP. Available from: [12] (06 March 2015). Bangkok medical software. Available from: [13] K. Selelanont, "Telling about 43 folders," District Health Office Rongkwang,