In 2005, the association of healthcare IT manufacturers (VHitG) launched an initiative to permit the exchange of intersectoral information and structured documents in a medical context. The objective was to work on a selection of therapeutic procedures and to promote an exchange of data and process information leading to integrated care, as well their development between the ambulatory and residential sector.
In the first implementation guide (Version 1.50), the use of medical electronic notes was described under HL7 CDA Release .
The guide gives installation instructions and enables programmers and users to develop and establish the communication of medical notes. In the support documents, there are examples of medical notes, style sheets, diagrams, rules and supplementary information that can assist with installation.
Contrary to the procedure established for the exchange of documents, in which information is transmitted in the form of free text, the new electronic medical notes support, amongst others, structured transmission and without loss of medical content. The added value for the referring doctor lies in the possibility to evaluate and treat the partial information of the medical notes.
It is in this way that, for example, it is possible to access the medical history or diagnoses in the patient’s documentation. Another advantage is the integration of communications by medical notes in the existing IT system.
Published last year, the directives are today largely accepted by users. Henceforth, they will include the presentation of medicines and laboratory results and are available for public viewing on www.vhitg.de.
Two extensions describe the structured transmission of laboratory data and the medication in the context of the medical notes. Other possibilities for the application of structured transmission exist.
It is in this way that a large proportion of hospital patients leave hospital with a recommendation of treatment and laboratory results. This data already captured in a structured fashion can be transmitted electronically in future with the exit report.
The treating doctor will also have the possibility to evaluate the data and for example to use the treatment to monitor medicines or to represent the laboratory results in a cumulative fashion beyond the limits of the hospital. The developments are based, like the medical notes, on international standards HL7 CDA Release 2. (HH)
Source and supplementary information on: www.vhitg.de/ (under ‘Intersectoral Communication Initiative’).