Electronic discharge letters using the Clinical Document Architecture (CDA).

Abstract

Communication between hospitals and general practitioners is often restricted to paper-based discharge letters. In order to meet the growing need for improved data communication between various actors in the healthcare domain, it is necessary to overcome the barriers of software heterogeneity and lack of standards. HL7's clinical document architecture (CDA) is a new tool to exchange clinical documents. In this paper we show how CDA can be used to share electronic discharge letters generated in the hospital information system with general practitioners. Ease-of-use and data security and integrity were the main design principles. Although there still remain technical and organizational issues to be solved, this is a promising method in order to enhance data exchange between hospital and primary care and to move towards an electronic patient record (EPR) crossing institutional borders.