Clinical Document Repository System for Electronic Health Record

Kim, Il Kwang; Lee, Jae Young; Kim, Il Kon; Cho, Hune; Kwak, Yun Sik

Abstract

OBJECTIVE
The needs of sharing clinical documents in order for health professionals to provide better diagnosis and treatment have been tremendously increasing. However, when a patient visits the hospital, current hospital information system doesn't allow for physicians to obtain patient's medical history even though she has some records in different hospital, because the lack of the standardization to overcome the incompatibility among heterogeneous systems. CDA(Clinical Document Architecture) of HL7(Health Level 7) is standardized technology in purpose of creating and exchanging various clinical documents. In this article, we discuss the method of exchanging, storing, and utilizing CDA and present the work of development and implementation based on CDR(Clinical Document Repository) framework reported earlier9).
METHODS
We convert paper-based discharge summary from each health institutions into CDA format. And in order to exchange, manage, and utilize those CDA, Registry structure of ebXML is introduced and applied.
RESULTS
The relationship among patients, physicians, clinical organizations, and clinical documents is well-organized and modeled. Because transfered CDA document can be easily registered and managed by complying with RIM structure of ebXML, this system can effectively exchange and share patient's CDA document when patient move to other area or among heterogenous systems.
CONCLUSION
This system can be utilized to categorize and store various clinical documents such as, ECG and Radiology reading report. In addition, this system suggests the potential of Electronic Health Record system that is able to communicate among heterogenous systems and manage the CDA documents via this CDR system.