Development of Standardization Clinical Document Generation System for Medical Information Exchanges

Patients' medical records in hospitals are complicated. It is difficult to exchange information among hospitals without followed standard format. In order to facilitate the exchange of medical information, a standardization project is supported by government and has developed guidelines for electronic medical records. More than 100 paper forms are collected from hospitals and have been reviewed by experts. Then, the fields in each form have been converted into the standardized format of Clinical Document Architecture (CDA), as a reference for inter-hospital information exchange. We have included real situation sample codes and the validation constrains for each of the forms. We have also set up a system in order to create the more than 100 types of standard document samples. Extensible Markup Language (XML) based CDA documents can be quickly generated automatically through the system. It will facilitate the medical information exchange and to enhance the quality of medical services.