joined+up+care

Joined-up Care with XML-EDI

Tim Benson

Electronic Point of Care Ltd

(tbenson@epoc.co.uk)

Joined up Care

GP SpecialistReferral

Report(Clinic LetterDischarge NoteDischarge Summary)

NHS Information Strategy - Actions

• By the end of 2002 Hospitals and all GPs will be routinely exchanging structured electronic messages for referrals, discharge summaries… (p38)

Proposed Approach

• The quickest route… will be through a national approach to clinical messaging between hospital and GPs… which builds on the “data push” model. This will require the implementation of nationally agreed structured clinical messages for key clinical communications between primary care and hospitals (para 2.84 Information for Health, 1998)

e-Message Benefits

• Speed

• Legibility

• Productivity

• Availability

• Reliability

• Patient care

• Hours not weeks

• Yes!

• GP and Hospital

• Yes!

• Yes!

• Yes!

Volumes

0

5

10

15

20

25

30

Millions pa

Referrals DischargeSummaries

Clinic Letters

Doctors

0

20

40

60 (,000)

GP Hospital + Community

The Many-to-Many Problem

• Each GP refers to many consultants in several hospitals

• Each consultant reports to many GPs using different systems in different ways

• Junior hospital doctors change every 3 months

Clinical Messages

• Referrals are dictated by GP, typed, signed and sent

• Discharge and clinic letters are dictated by consultant or registrar, typed signed and sent

• Immediate discharge documents are written by HO on the ward on 4 or 5-part paper (Patient, GP, Notes, Pharmacy and Coding)

User Needs

• All or nothing - send 100% electronic

• Integration with own system– Analysis– Follow-up actions– Consulting room use– Answer queries

• Ensure reliability and safety - do not lose clinical messages - people may die

Background work

• 1993 CEN TC251 PT3-024 "Messages for Patient Referral and Discharge” ENV12538:1997

• 1995 NHS Version 1 Trial NHS EDIFACT Messages for Communications between General Practitioners Volumes 1, 2 and 3 (E5193,4,5)

• 1996-97 Nuneaton GPPL Trailblazer• 1998 Change Notice 2• 1999 Kettering XML-EDI project

Trailblazer Lessons

• Formatting– EDIFACT has no means of including layout

instructions (not even a blank line!)

• Headings and Codes– Genuine clinical safety concerns

• Clinical Safety– Incorporated into RFA-4+ and RFA-5

regulations for GP systems

Clinical text is ambiguous

Found unconscious in the street. No family history of ischaemic heart disease according to his 12 year old daughter who was injured when trying to stop him falling (small laceration under her right eye - sutures not required). Admitted to intensive care. Attempted to contact wife.

• Who did what?• This text can be understood by a human but

not by a machine

Safety is Paramount

Acknowledgement at both transport and application level

Validation by both sender and the receiver Automatic + manual patient matching Routing to alternate recipient Actions specified and carried out before messages

are moved from task list Deletionless messages; if a user edits a message, a

copy is kept of the original Full audit trail.

Kettering XML/EDI Project

• Aim to provide tested, scrutinised NHS standard messages for national adoption

• Funded by NHS IA

• EMIS at GP end

• EPOC at hospital end

• CIC and CPL prepare XML Schemas

• Clinical Scrutiny by RCGP/ACIG

Why XML?

• Human and Computer readable

• Rigorous structure (easy to program)

• Does what is required

• Massive industry support

XML Syntax

• XML tags for structured data (admin/metadata)

• HTML tags for formatted data (clinical)

• No need for style sheets for the message itself

EDI Principles Apply

• Computer to computer communication with end-to-end integration

• Caldicott (identifiers not person details)

• Patient matching (automatic and manual)

• Reliability (acknowledgement required)

• Security (encryption)

• Safety is paramount

Referrals - Hospital End

e-GP EPOCServer

PAS

DecryptionParsing

Appoint-ments

SecretaryConsultant

MedicalRecords

PAS look-upRegister new patients

PrintPrioritise

O/P Appointments

X.400

Clinic/Discharge LettersDoctor

Dictates

SecretaryTypes

Sign &Correct

Print, file & post e-GP

Paper practice

Uses EPOCTemplate

EPOC Server

StructuredData

Discharge Note

PAS

Patient Record

CodingDept

GP via Patient

GP by post

Discharge Database

EPOCServere-GP

Referral XML Message

• Header

• Patient Information

• Agents Directory

• RequestedService

• PatientAdminInfo

• ClinicalReferral

Discharge/clinic XML Messages

• Header

• Patient Information

• Agents Directory

• RequestedService (Referral)

• MsgRef (Report)

• ReportedService (Report)

• PatientAdminInfo

• ClinicalReferral or Clinical Report

Header

• MessageType• MsgRcptAckRequest• MsgUrgency• MsgStatus• MsgId• MsgIssueDate• MsgSender• MsgRecipient• ServiceRequester• ServiceProvider

Patient ID

• NHSNo• HospitalNo• PracticeNo• PatientSurname• PatientGivenName• PatientMiddleName• PatientTitle• PersonNameType• BirthDate• Sex• PostCode• UnstructAddressLine (5)

Healthcare Agents

• GPId• GPName• PracticeId• PracticeName• SpecialistId• SpecialistName• SpecialtyCode • ProviderId• ProviderName

Patient Admin Info

• FormerName

• CorrespondenceAddress

• Telecom

• RegisteredGP

Referral Data

• ReferralNumber

• TransportInfo

• PaymentCategory

• ServiceEventType

• EventUrgencyStatus

Report Data

• MsgRef (referral reference)• ServiceReportStatus• ServiceEventType• RelDate

– Date of Consultation, – Admission Date, – Discharge Date, – Follow-up Date

• AdministrativeOutcome

Clinical Data

• HTML

• #CDATA within XML tags

• Formatted, not structured

• Full renderable letter sent as HTML

Acknowledgements

• All messages are acknowledged

• Responsibilities– Sender must check that ACK is received– Receiver must report acknowledged messages

that have subsequent problems

Conclusions

• Why it should work (better than before)– Syntax and semantics– Process– Safety, security and reliability

• Results including clinical scrutiny (Autumn 1999) to be presented to Clinical Data Standards Board