SS-MIX: a ministry project to promote standardized healthcare information exchange.

OBJECTIVES: To promote healthcare information exchange between providers and to allow hospital information systems (HIS) export information in standardized format (HL7 and DICOM) in an environment of wide-spread legacy systems, which only can export data in proprietary format. METHODS: Through the Shizuoka prefecture EMR project in 2004-2005, followed by the ministry's SS-MIX project, many software products have been provided, which consist of 1) a standardized storage to receive HL7 v2.5 messages of patient demographics, prescription orders, laboratory results, and diagnostic disease in ICD-10, 2) a referral letter creation system, 3) a formatted document creation system, 4) a progress note/nursing record system, and 5) an archive/viewer to incorporate incoming healthcare data CD and allow users to view on HIS terminal. Meanwhile, other useful applications have been produced, such as adverse event reporting and clinical information retrieval. To achieve the above-mentioned objectives, these software products were created and propagated, because users can use these software products, provided that their HIS can export the above information to the standardized storage in HL7 v2.5 format. RESULTS: In 20 hospitals of Japan, the standardized storage has been installed and some applications have been used. As major HIS vendors are shipping HIS with HL7 export function since 2007, HIS of 594 hospitals in Japan became capable of exporting data in HL7 v2.5 format (as of March 2010). CONCLUSIONS: In high CPOE installation rate (85% in 400+ bed hospitals), though most of them only capable of exporting data in proprietary format, prefecture and ministry projects were effective to promote healthcare information exchange between providers. The standardized storage became an infrastructure for many useful applications, and many hospitals started using them. Ministry designation of proposed healthcare standards was effective so as to allow vendors to conform their products, and users to install them.

High speed clinical data retrieval system with event time sequence feature: with 10 years of clinical data of Hamamatsu University Hospital CPOE.

OBJECTIVES: This paper illustrates a high speed clinical data retrieving system, from 10 years of data of operating hospital information system for the purposes of research, evidence creation, patient safety, etc., even incorporating time sequence of causal relations. METHODS: Total of 73,709,298 records of 10 years at Hamamatsu University Hospital (as of June 2008) are sent from HIS to retrieval system in HL7 v2.5 format. Hierarchical variable length database is used to install them. RESULTS: A search for "listing patients who were prescribed Pravastatin (Mevalotin and generic drugs, any titer)" took 1.92 seconds. "Pravastatin (any) prescribed and recorded AST >150 within two weeks" took 112.22 seconds. Searching conditions can be set to be more complex, connected by Boolean operator and/or. This system called D*D is in operation at Hamamatsu University Hospital since August 2002. It is used for 48,518 times (monthly average of 703 searches). Neither searching, nor background export of data from HIS caused delay of routine operating CPOE. CONCLUSIONS: Search database outside of routine operating CPOE, with daily export of order data in HL7 v2.5 format, is proved to provide excellent search environment without causing trouble. Hierarchical representation gives high-speed search response, especially with time sequence of events.

Implementation of multi-vendor DICOM standard image transfer in hospital wide ATM network.

At Hamamatsu University Hospital, an ATM + FDDI network was installed in January 1995, when the hospital information system was upgraded. With its unique 'wheel' shape configuration, FDDI automatically backs up in case of an ATM switch failure. The authors implemented a DICOM image database server and DICOM viewer in the Hamamatsu University Hospital ATM + FDDI network. The DICOM standard worked well between different vendor products. In sending 512 x 512, 2 byte CT images, 40% of the transfer time was spent for the network data transfer, which is 70% of the theoretical value of 10 Mb peripheral transfer rate. Meanwhile, ATM load factor increased less than 0.5%. As we have a very fast data transfer network, we must check display speed, hard disc access time, PC bus speed, and display software, in order to enjoy the high speed network transfer fully. The sequence of image transmission within a study is not stated in the DICOM document and is depending on the server. Therefore, there should be an agreement between server and clients, still more than DICOM, in order to make better PACS.

MERIT-9: a patient information exchange guideline using MML, HL7 and DICOM.

To realize clinical data exchange between healthcare providers, there must be many standards in many layers. Terms and codes should be standardized, syntax to wrap the data must be mutually parsable, then transfer protocol or exchange media should be agreed. Among many standards for the syntax, HL7 and DICOM are most successful. However, everything could not be handled by HL7 solely. DICOM is good for radiology images, but, other clinical images are already handled by other 'lighter' data formats like JPEG, TIFF. So, it is not realistic to use only one standard for every area of clinical information. For description of medical records, especially for narrative information, an standard generalized mark-up language, document type definition (SGML DTD) for medical information, called MML (medical markup language) had been created in Japan. It is already implemented in more than ten healthcare providers. However, it is again not realistic to use MML solely for clinical information in various level of detail. Therefore, we proposed a guideline for use of available medical standards to facilitate clinical information exchange between healthcare providers. It is called MERIT-9 (Medical Records, Images, Texts, -Information Exchange). A typical use is HL7 messages, DICOM files, referred from an MML file in a patient record, as external entities. Both MML and MERIT-9 have been research projects of Japanese Ministry of Health and Welfare and the purpose is to facilitate clinical data exchanges. They are becoming to be used in technical specifications for new hospital information systems in Japan.

Patient information exchange guideline MERIT-9 using medical markup language MML.

To realize clinical data exchange between healthcare providers, there must be many standards in many layers. Terms and codes should be standardized, syntax to wrap the data must be mutually parsable, then transfer protocol or exchange media should be agreed. Among many standards for the syntax, HL7 and DICOM are most successful. However, everything could not be handled by HL7 solely. DICOM is good for radiology images, but, other clinical images are already handled by other "lighter" data formats like JPEG, TIFF. So, it is not realistic to use only one standard for every area of clinical information. For description of medical records, especially for narrative information, we created SGML DTD for medical information, called MML (Medical Markup Language). It is already implemented in more than 10 healthcare providers in Japan. As it is a hierarchical description of information, it is easily used as a basis of object request brokering. It is again not realistic to use MML solely for clinical information in various level of detail. Therefore, we proposed a guide-line for use of available medical standards to facilitate clinical information exchange between healthcare providers. It is called MERIT-9 (MEdical Records, Images, Texts,--Information eXchange). A typical use is HL7 files, DICOM files, referred from an MML file in a patient record, as external entities. Both MML and MERIT-9 are research projects of Japanese Ministry of Health and Welfare, and the purpose is to facilitate clinical data exchanges. They are becoming to be used in technical specifications for new hospital information systems in Japan.

Proposal of a new Internet standard for DICOM: DICOM-QR URL.

This paper proposes a new Internet standard that is combination of two standards in different domain, Internet and medical informatics. The both standards are described briefly in this paper. We describe how to combine them into a Internet standard. With a new standard, there are several advantages for medical information systems. The standard should be established by the following way of the Internet standards.