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Presenting XML-based medical discharge letters according to CDA.
H B Bludau1, A Wolff, A J Hochlehnert
1University of Heidelberg, Internal Medicine Dep. II, Bergheimerstr. 58, D-69115 Heidelberg, Germany,
Methods of Information in Medicine
|December 5, 2003
Summary
This study introduces an XML-based prototype for clinical discharge letters, enhancing the HL7 Clinical Document Architecture (CDA) standard. The prototype facilitates hierarchical information structuring for improved patient data management.
Area of Science:
- Health Informatics
- Medical Informatics
- XML Standards in Healthcare
Background:
- The HL7 Clinical Document Architecture (CDA) is a key XML-based standard for clinical documents.
- Current standardization efforts for healthcare data lack routine usability and hierarchical information differentiation.
Purpose of the Study:
- To develop a routinely usable XML-based solution for clinical discharge letters.
- To address the need for hierarchical information structuring in patient treatment overviews.
- To improve patient data management and accessibility for healthcare staff and patients.
Main Methods:
- Retrospective analysis of 120 discharge letters (60 cardiology, 60 gastroenterology).
- Extraction of letters from a central hospital information system over one year.
- Development of an XML-based prototype and XSL-stylesheet.
Main Results:
- An XML-based prototype for medical discharge letters was successfully implemented.
- The prototype represents required information units and elements.
- An XSL-stylesheet generated a platform-independent, reusable representation of discharge letters.
Conclusions:
- Defining information elements and units can advance CDA levels two and three.
- A novel method for generating discharge letters using XML data is presented.
- The XML prototype enables specialized views for generating discharge documents in internal medicine.