It’s hard to believe the speed at which industry introduces new technologies! Better methods, new brands, and new devices. We call it e-Business. The Internet, however, has introduced a true cultural change, because it blurs the boundary between industry segments. Now, big hospitals AND individual practitioners are able to share - and automate - business processes with patients, insurance companies, banks, suppliers, service companies, libraries and vice-versa.

Unfortunately, healthcare has proven to be a woefully uneconomic industry when it comes to information management. This is due poor exchange of information between existing healthcare providers, applications, and devices. A common complaint is that patients must fill out virtually identical forms at every healthcare provider's office, since there is usually no provision for sharing such data even across departments of the same organization. Medical tests are repeated needlessly simply because it is cheaper and faster to re-do the tests than to locate the records at another organization. Many errors are introduced when transcribing handwritten notes or re-keying results read from one system into another; and the lack of access to a complete medical record often causes different doctors and pharmacists to prescribe drugs with possibly harmful interactions. XML is increasingly being applied to help solve these problems.

XML's greatest advantage is that it is a user-driven, open standard for exchanging data both over corporate networks and between different enterprises, notably over the Internet. XML’s biggest potential lies undoubtedly in its ability to mark up mission-critical document elements self-descriptively. XML transports the meta data (the information about the data) together with the relevant data, thus allowing its meaning to be easily interpreted. In addition, XML enables suitably coded documents to be read and understood without difficulty by both humans and machines.

The principal motivation behind firms' present endeavors to integrate is their desire to secure future business advantages for themselves by ensuring that they are fit for global electronic commerce. The fully automated processes which are necessary to achieve this are considerably simplified because, XML, as a text-based format is independent of system platforms, programming languages and applications in which XML data is subsequently evaluated and edited. Investments in existing systems are protected because these systems can be integrated easily with XML-based and Web-based business processes.

XML is an open standard for meta languages controlled by the World Wide Web Consortium. It was developed by users cooperating with industry and is being improved continuously. XML's overwhelming success is attributable above all to its declared objective of making data exchangeable worldwide across different applications and platforms.

From the user’s point of view, this approach can reduce costs tremendously, because only a few conversion solutions are necessary to integrate a large number of discrete, proprietary solutions.

Despite this, software manufacturers who develop and implement industry-specific initiatives and applications for XML still retain a considerable amount of freedom to proliferate their own ideas. Providing this does not detract from the actual aims of XML or related standards such as XSL, XSLT, XPath, etc., the outcome will be specific, discrete solutions whose market success will continue to depend on the acceptance they achieve among users. There will be no lack of room for good ideas, as long as they do not conflict with XML's original purpose.

The Health Level Seven organization has been developing data interchange standards for more than 12 years, and is in the process of developing XML-based versions of their electronic data interchange messages.

The progress of this effort was demonstrated in April 2000 at an HL7 interoperability demonstration at the Healthcare Information and Management Systems Society (HIMSS) meetings in Dallas, Texas. The objective of the HIMSS interoperability demo was to show the power of HL7’s XML specifications to allow interoperability between diverse systems, some of which support only the "legacy" HL7 EDI-like formats, and some supporting the proposed XML formats.

At HIMSS, a number of administrative systems were exhibited that created and updated patient records and produced orders for laboratory tests plus a laboratory system that responded to those orders with (simulated) data. In addition, there were also transcription systems that produced documents containing reports from physicians and other professionals, a "hub" that does message routing and translation, and two database management systems. One of these two was SQL-based and the other one was Software AG’s Tamino, a native XML database.

A clinical scenario was demonstrated in which a patient comes to an emergency room with chest pain, various tests are made and the resulting data stored. One part of the demo brilliantly illustrated XML’s value. An emerging HL7 standard known as the Clinical Document Architecture defines an XML format for storing such unstructured information as nurses’ notes, physicians’ examinations, etc.

XML as a data interchange format is compelling, primarily because it gives developers:

1. a language with which to more easily identify interoperability problems; and
2. a common syntax and tool set with which to fix them.

But putting XML at the center of the system, i.e., storing it natively in Tamino and accessing/processing it with standard Web tools, gives users even more advantages. I suspect that we’ll see the same pattern in the real world that I observed at the demo. That is: it will cost healthcare organizations and system integrators far more to develop solutions based on XML-enabled RDBMS applications than it would to store XML natively in Tamino. This is because with native XML, standard tools can be used to build the necessary queries, processing logic, and stylesheets can be used to adapt the presentation of the data.

The biggest business benefit of using XML today is simply that everyone else is either using XML or planning to use it. So it will be relatively easy to find tools, programmers, tutorials, etc. to handle the groundwork, letting you focus on the stuff that requires substantial expertise. To prove this, look at the following article about the Swiss HIV Cohort Study. This system was literally put together by a physician and a student intern programmer!

"XML documents represent all the structures found in patient files one-to-one, for example the cover sheet and doctor's entries. Doctors and medical researchers have easy access to the files through a browser and can even understand the clear structures years after the original entry." (Dr. Walter Fierz, Head of the Immunology Division at the Institute for Clinical Microbiology and Immunology of the canton of St. Gallen)

The use of modern information technology in health care is often a controversial subject. However, its value for the analysis of medical statistics to find common characteristics of diseases is undisputed. The SHCS Web project (SHCS = Swiss HIV Cohort Study), started in 1997 by an institute in the Swiss canton of St. Gallen and an institute from the University of St. Gallen, is an example of how valuable technology can be. Swiss AIDS researchers depend on Tamino, Software AG's XML database management system, because they can store patient records one-to-one in XML structures.

In 1988, nine years before the Web project was launched, the SHCS scientists began long-term studies of HIV patients in Switzerland. Their goal was to learn more about the progression and spread of AIDS. So far, a total of about 10,000 HIV patients in hospitals and clinics in Basle, Berne, Geneva, Lausanne, Lugano, St. Gallen and Zurich have taken part in the study. Around 4,500 of the patients are currently in advanced stages of the disease. The patients' case history, clinical and sociological data and laboratory test results are assessed, rendered anonymous and stored in a central SQL database in Lausanne. Integrating all this patient information, particularly regarding treatment, proved to be quite difficult at first.

In 1998, Dr. Rolf Grütter's and Dr. Walter Fierz's team developed an XML-based solution - a prototype application called Electronic Study Form (ESF). Early on they knew they wanted to use XML: "What convinced us about XML more than anything else was its potentially universal availability on the Web, its independence of any proprietary system and its document orientation. By this we also mean its good legibility and its suitability for preserving medical records," explains Grütter, Head of the research division, Knowledge Media for Professional Communities (KMPC), at the Institute for Media and Communication Management at the University of St. Gallen.

"Alternatives to XML such as CORBA Med turned out to be much too complex for our purposes," says Dr. Walter Fierz, Head of the Immunology Division at the Institute for Clinical Microbiology and Immunology of the canton of St. Gallen. ESF is written in Dynamic HTML, JavaScript and MS Data Binding and uses XML as its universal interchange format. Since the summer of 1999, laboratory data from the various sources has been stored in Tamino in XML - an ideal solution according to Fierz: "All relevant information is now available centrally." In the initial phase of the project, the data was entered and stored in XML format locally. Subsequently it was made available globally to all those involved in SHCS. "We hoped that the XML application would accelerate our processes for capturing, transmitting and storing data and reduce the number of errors made in data entry. We are evaluating this on a continuous basis by comparing the old processes with the new ones," says Grütter. "In the next phase of the project, XML will enable applications such as specialized systems for diagnosis and treatment to be linked up."

XML is not a panacea for the woes of the world’s healthcare systems, it is just a simple, standardized mechanism for presenting data in a "self-describing" way. It is very similar to HTML, but rather than containing a fixed set of "tags", allows organizations to define their own schemas for their particular needs. There has been a recent leap in Internet usage by the healthcare industry to manage information. However, HTML, the most popular language for creating Web sites, has many limitations. These limitations become obvious when you try to search for information on the Internet and receive links to irrelevant Web pages and imprecise information.

With XML, humans and computers can tell and interpret the difference between a <DIAGNOSIS> tag and <SYMPTOM> or a <Medical.Record.Number> from a <Social.Security.Number>. In addition, XML takes the pain out of integration. Because XML is self-describing it can be easily interpreted by all XML-enabled applications (and every serious Internet application vendor provides that). Because it separates content from presentation, the same information can be easily displayed in different formats and devices, like an Internet Browser, CD, brochure or a mobile phone (e.g. for direct remote advice). XML is rapidly evolving as the key enabler for new online economy of Electronic Business. By adopting XML now, enterprises can transform their existing multimillion-dollar investment in hardware and software into an asset that can be used to derive revenue growth and productivity benefits in the new information millennium.

Health care and other industries have the legal obligation to store documents for decades. How will they ensure the new digital documentation will be readable 30 years from now? They will have to manage and exchange new types of information, including Internet pages and biometrics such as retina control or fingerprints.

XML offers a brilliant solution here as well. With the standards related to XML, companies can describe the content, relationship and meaning of any kind of documents in plain text. This information i.e. indices, patient data and its meaning can be stored and exchanged together with the documents to maintain information integrity in an XML-database. And, since XML is self-describing and extensible, this information will remain readable forever, even if the applications that created it are long gone and forgotten.