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Extensibility Sensibility

March 1, 1998
by Charlene Marietti
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Hailed as heir-apparent to the Web throne now occupied by HTML (HyperText Markup Language), XML (Extensible Markup Language) promises a standardized way for systems to talk to each other--without sacrificing extensibility (a major drawback to HTML). Think of it as a dialect related to HTML, within the mother-tongue of Structured General Markup Language (SGML). And since it’s vendor and platform-independent, XML is a dialect with immediate opportunities.

Businesses will soon deploy all kinds of applications using XML to move structured data around on intranets and the Internet this year, predicts Jon Udell, BYTE magazine’s executive editor, new media. Many vendors are actively harnessing the technology into electronic data interchange solutions under such ventures as Open Financial Exchange, where the World Wide Web Consortium recommended XML standard is the basis for Internet commerce. In healthcare, it may become the "open sesame" on patient health information now scattered throughout the care delivery enterprise.

Medical records killer app?
SGML/XML technology brings together two very important issues under one standard: a Web-speak data-exchange format and industry specificity. If SGML/XML technology delivers on its promises, it will revolutionize the Web and related Web-based applications--and just may enable the development of killer apps for electronic medical records.

Because SGML/XML applications conform to machine processable data structure--as opposed to most current applications that dictate data structure--the technology can facilitate the exchange of intelligible medical record information to caregivers anywhere in the system, says John Spinosa, MD, PhD, director of pathology, Central Laboratory, Pathology Medical Group, La Jolla, Calif.

With XML and SGML underlying technology, users can search for information in ways that take advantage of narrative text, pieces of text or any other data bits on the fly. Tags within the SGML document identify data, effectively making the document a database.

To facilitate the care delivery process while respecting the privacy rights of the patient, "a minimum data set must belong to the patient to accompany that patient through the network of health services," says Spinosa. Patient information should not be locked up by who or what created it, he says. All commercially available electronic medical record applications do a great job--so long as the product controls the entire data entry, storage and retrieval operations. Once the data is exported, the information transfers as an ASCII file with all the intelligence and lookup tables residing outsideof the ASCII data file. He calls that a "gotcha" both for the patient and for legitimate government interests. Information inaccessibility at the local health delivery level results in inconveniences and inefficiencies for the patient and provider; at the national level, such data barriers stymie public health efforts.

If it is possible to exchange information easily and quickly, there is no need to have all the information in one place. Under SGML/XML, the system only has to manage where the information is--the metadata--not the information itself.

If the caregiver can readily access the information, the issue of the data storage site becomes much less important. Spinosa suggests this could lead to models of cooperative business arrangements to finance data storage and transfer operations.

Although security is a hot button in electronic medical record issues, the issue of data ownership and management is fast becoming important. Related (but not restricted to privacy), ownership is also about maintaining control of personal information. Spinosa agrees with Tom Lincoln, MD, Rand Corp., Santa Monica, Calif., who says, "The medical record is owned by the patient, and the care providers have fiduciary responsibility to take care of it." In that line, he does not believe that patients want their health records made accessible in their entirety to all providers at all times. XML, he thinks, will add a layer of anonymity that will allow patients to maintain a sense of ownership.

Rethinking the paradigm
Throwing technology solutions at a cultural problem doesn’t resolve the medical records problem, says Anil Sehti, chief technology officer, Sequoia Software, Inc., Columbia, Md. Given a flexible database and direct data capture by the physician using a keyboard, many medical records storage and access problems could have been accomplished on any hardware platform under any operating system long ago--if technology alone were the answer. For him, XML overcomes many of the difficulties surrounding patient medical records, while supplying a means for legacy systems to achieve compliance with emerging standards. The medical record problem is entirely too complex for conventional technologies, he continues, suggesting that if decision makers disregard the power of SGML and XML, they may end up waiting for products that cannot be built.