XML: A records and billing solution for health care
By Bethany Schroeder, RN, MFA, MS
Health Care Consultant
Since the advent of the computer and its associated data applications, leaders and information professionals in all sorts of industries have noted the need for a system that could standardize documentation. In many respects, the system has been available for years. Now we have an efficient, easily implemented tool, Extensible Markup Language (XML), to make the solution universal.
XML is a subset of a widely used, nationally recognized language known as Standard Generalized Markup Language (SGML). XML allows you to write information once and use it repeatedly in virtually limitless ways for as many audiences and purposes as you can imagine. To understand and appreciate the potential of XML, you should know a little about the history of SGML.
More than 20 years ago, SGML was developed to address the requirements of electronic documentation. In 1986, the international standards community recognized SGML (ISO 8879), precipitating its widespread use in industries such as aerospace, automobile manufacturing, and computer technology - all of which had and still have large-scale documentation needs.
By adopting SGML, these industries saved millions of dollars in writing and publishing costs.
Designed with structure in mind, SGML uses a document type definition (DTD) to describe the way information can be presented. The DTD specifies rules about the relationships between structures as in, for example, "a chapter will begin with a heading" and report will have a title and one or more paragraphs."
SGML structures content through "tags" that identify parts of a document, such as paragraphs and lists. Tags consist of names, usually short words or parts of words, like para for paragraph, enclosed in angle brackets. A tag could look like this: .
SGML tags structure the text to which they are applied so that a machine can process a tagged or marked up version of the text. SGML can be considered as human-readable code that people with little more than a word-processing background can learn to use. Many companies expect their technical writers to produce materials in SGML, which expedites the publication of manuals and reduces publication costs.
Because SGML is a standard, it is not proprietary. You can buy inexpensive SGML tools off the shelf today, install them, and begin to mark up text without ever contacting a vendor. SGML is, in fact, vendor-, device-, and system-independent. Macintosh, PC, and Unix platforms are compatible with SGML. Furthermore, the design of SGML accommodates the need to reuse information in any number of ways. For instance, you could render a document in SGML - for example, this article - with references or editor's notes, without re-formatting the information. Instead, you could mark up the article with tags to indicate which parts of the text are notes. SGML will let the application render the note as either references or editor's notes, depending on what instructions you give.
Once you've indicated which parts are the notes, an SGML-capable application will give you whichever treatment you want whenever you want it.
On the other hand, SGML contains some disadvantages. It is a complex standard, and much of it borders on the arcane. A very limited SGML tag language called Hypertext Markup Language (HTML) was developed in the early 1990s for the Internet. HTML employs hard-wired tags that you can't alter for different purposes without using a proprietary version of the application, thus limiting its reusability and causing the user to wait for the standard to change, which requires a decision from the standards body that oversees its conformity.
In an effort to remedy the situation, a working group in the World Wide Web Consortium (W3C) has recently released XML. In February, XML was recognized as an international standard, one that industries and governments worldwide anticipate will make more efficient communication and publication possible - not only on the Internet but also in other media.
The extensibility of XML is one of its important features: You can specify tags when you mark up data, which will allow for more complete sorting, searching, indexing, and organizing of information. In health care, for instance, outcomes could be tracked with a fraction of the resources required using conventional, proprietary tools. Furthermore, just as with SGML, one of the design principles of XML is that users own their data and should be able to manipulate it. Users of XML can look at and organize their information without the expensive and time-consuming consultations of a vendor.
Do we need a new documentation system?
But why would health care organizations consider adopting a new system of documentation, no matter how easy and inexpensive it is? Unless you are a member of an integrated or affiliated system that uses the same platforms and programs, you cannot share information with others.
Perhaps, more than any other industry, health care organizations gain an advantage by collaborating in the creation and dissemination of patient-related information. Regulatory and reimbursement requirements, like evaluation and management (E/M) and the Outcome and Assessment Information Set (OASIS), provide ready-made opportunities for testing XML's muscle.
One health care body that has been working on ways of sharing information is Health Level Seven (HL7). An international standards organization, HL7 has promoted the development and adoption of information tools for more than a decade. Some of its members have formed a Special Interest Group (SIG) called the SGML/ XML SIG - one of its purposes is to address issues surrounding information across systems.
Organized over a year ago, the SGML/XML SIG has produced examples of SGML and XML documents and is collaborating with other working and special interest groups within HL7 to develop compatible tools that address multiple data and documentation needs.
You can review the efforts of HL7 at its Web site: http://www.hl7.org. You can also read the XML specification at http://www.w3c.org/xml. And, of course, you can get involved in setting documentation standards by joining HL7. Membership information is available on the HL7 Web site.
[Editor's note: Bethany Schroeder is a writer, educator, and consultant with more than 20 years of experience in the field of health care, including acute care, home care, and hospice. She has worked with HL7 since 1997 and has been an active member of the SGML/XML SIG since its inception. For more information, contact Schroeder by e-mail at: [email protected].]
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