Original Article
Healthc Inform Res. 2010 December;16(4):281-289.
doi: 10.4258/hir.2010.16.4.281
pISSN 2093-3681 • eISSN 2093-369X
Implementation of Medical Information Exchange
System Based on EHR Standard
Soon Hwa Han, MS1, Min Ho Lee, BS1, Sang Guk Kim, BS1, Jun Yong Jeong, BS1, Bi Na Lee, MS1,
Myeong Seon Choi, MS2, Il Kon Kim, PhD3, Woo Sung Park, MD, PhD4, Kyooseob Ha, MD, PhD5, Eunyoung
Cho, MS6, Yoon Kim, MD, PhD7, Jae Bong Bae, PhD 7
1
R&D Center, ezCare Tech Co. Ltd., Seoul; 2R&D Center, UBcare, Seoul; 3IHIS System Development Center, Kyungpook National University, Daegu; 4Depart-
ment of Pediatrics, Dankook University Hospital, Cheonan; 5Department of Psychiatry, Seoul National University Bundang Hospital, Seoul National Univer-
sity College of Medicine, Seongnam; 6Department of Medical Information Center, Seoul National University Bundang Hospital, Seongnam; 7R&D Center for
Interoperable EHR, Seoul, Korea
Objectives: To develop effective ways of sharing patients’ medical information, we developed a new medical information ex-
change system (MIES) based on a registry server, which enabled us to exchange different types of data generated by various
systems. Methods: To assure that patient’s medical information can be effectively exchanged under different system envi-
ronments, we adopted the standardized data transfer methods and terminologies suggested by the Center for Interoperable
Electronic Healthcare Record (CIEHR) of Korea in order to guarantee interoperability. Regarding information security, MIES
followed the security guidelines suggested by the CIEHR of Korea. This study aimed to develop essential security systems for
the implementation of online services, such as encryption of communication, server security, database security, protection
against hacking, contents, and network security. Results: The registry server managed information exchange as well as the
registration information of the clinical document architecture (CDA) documents, and the CDA Transfer Server was used to
locate and transmit the proper CDA document from the relevant repository. The CDA viewer showed the CDA documents
via connection with the information systems of related hospitals. Conclusions: This research chooses transfer items and de-
fines document standards that follow CDA standards, such that exchange of CDA documents between different systems be-
came possible through ebXML. The proposed MIES was designed as an independent central registry server model in order to
guarantee the essential security of patients’ medical information.
Keywords: Electronic Health Record, VPN, Web Service Security Enhanced, Health Level 7 Standard, CDA R2
Received for review: August 3, 2010
Accepted for publication: December 15, 2010
I. Introduction
Corresponding Author Since now, when a patient is transferred to another hospital,
Min Ho Lee, BS the patient needs to bring his/her own records and submits
ezCaretech Co. Ltd R&D Center, 125-1 Kwansoo-dong, Jongno-gu, to the newly assigned doctors [1]. To lessen this inconve-
Seoul 100-420, Korea. Tel: +82-70-7410-4309, Fax: +82-2-3672-
0356, E-mail:
[email protected] nience, data transferring, or data exchanging techniques
have been developed. The biggest limitation on this issue
is that the records are in various forms by each doctor or
each institution. To overcome this barrier, some web-based
This is an Open Access article distributed under the terms of the Creative Com- information sharing systems have been developed in some
mons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduc- General Hospitals to communicate with their affiliated clin-
tion in any medium, provided the original work is properly cited. ics to eliminate manual procedures recently. However, these
ⓒ 2010 The Korean Society of Medical Informatics kind of systems are not proper for the nation-wide standard
Soon Hwa Han et al
model but for their affiliated medical facilities [2]. The elec- terminologies and security of data and system.
tronic healthcare record (EHR) is an information system Considering the above issues, this study adopted ebXML
that integrates electronic medical record (EMR) maintained as data transmission standard suggested by Center for In-
by individual hospitals to effectively exchange histories of teroperable Electronic Healthcare Record (CIEHR) of Korea
patient’s treatment record scattered around medical facilities in order to transmit messages between various systems.
[3]. Furthermore, in this study, the Web Service technique was
In terms of improved medical service quality, better acces- adopted to connect EMR systems of each hospital. In addi-
sibility and enhanced safety for patients, EHR provides vari- tion, the international standard of the clinical document ar-
ous benefits. Based on the electronic treatment information chitecture (CDA) R2 was used to enable nationwide transfer
and clinical decision support system, EHR can check drug of medical records for the information exchange. We imple-
interactions to reduce prescription errors and constantly mented the centralized EHR Registry Server which contains
monitor pharmaceutical side-effects of safe medical services. information to share. As a result, it enabled users to retrieve
Moreover, by making individual treatment information and distribute the CDA document from CDA Repository by
available regardless of time and location, EHR can increase patient’s index.
patient’s right to know, improve the ability to manage dis- The EHR Registry Server is the center to store and manage
eases, and alleviate the asymmetry between the medical staff information on hospitals, patient’s medical information and
and the patient [3]. EHR can also intensify personal infor- their consent to release of their medical records.
mation protection by implementing managerial, technical
and physical measures against misuse and abuse of patient’s 1. System Process and Architecture
treatment information [4]. The MIES developed through this study have been tested by
The primary aim of this research was to build a medical Seoul National University Bundang Hospital (SNUBH) as a
information exchange system (MIES) which made it possible general hospital and 33 nearby physician's clinics. Figure 1
to exchange medical information between various medical shows the delivery process model of referral from a physi-
information systems of hospitals and also guarantees the cian's clinic to a general hospital. The physician’s clinic sends
interoperability between medical information systems of the a referral message to the Registry Server when referring the
participating institutions. patient and it will store the CDA document at its CDA Re-
pository. Then it sends referral message to a requested hos-
II. Methods pital. The requested hospital sends the patient’s information
to the Registry Server and retrieves the CDA document after
To enhance the reliability and effectiveness of the medical checking the registry information. Also referral reply and
information exchange between different medical institu- Information for Request are delivered as reverse way. Figure
tions, the following factors is considered importantly: well 1 focuses on system architecture and technical approach of
screened items, data transmission methods, standardized the MIES for medical information exchange process.
Figure 1. Referral process from phy-
sician's clinic to general
hospital through medical
information exchange sys-
tem (MIES). CDA: clinical
document architecture.
282 www.e-hir.org doi: 10.4258/hir.2010.16.4.281
Implementation of MIES Based on EHR Standard
Figure 2. Medical information exchange system architecture. EMR: electronic medical record, CDA: clinical document architecture,
EHR: electronic health record.
The MIES was designed to exchange CDA documents be-
tween designated medical facilities through the CDA Trans-
fer Server with helping of Central Registry Server. The main
function of this server is to manage the index information
of patients subject to information exchange and facilitate the
exchange of CDA documents via the CDA Transfer Server
with this index information [5]. Figure 3. Service architecture of cal information exchange sys-
The MIES has two servers and needs to be connected to an tem (MIES). CDA: clinical document architecture.
adaptor. This adaptor plays a role of intermediary to trans-
mit the CDA document and messages. The Registry Server
stores the patient’s information according to predefined locates the proper CDA document from the relevant reposi-
schema and generates the index of patient, and it is used for tory and transmits it [6]. The CDA viewer shows the CDA
searching CDA documents. Using the produced index of documents through connection with information systems of
the patient, the CDA Transfer Server extracts the relevant hospitals related (Figure 3).
CDA documents from the CDA Repository of the physician’s
clinic for transmission. Then, the transmitted data is stored 2. Application Methodology of CDA
at the repository of the requested hospital (Figure 2). To share medical information between medical institutions,
The MIES is composed of three categories of services: The it is necessary to determine items to be exchanged. The items
registry server manages information exchange and the reg- are defined in ‘HL7 CDA’ format which is the standard for
istration information of the CDA documents, and the CDA XML-based CDA exchange. The used version is release 2
Transfer Server is used for the registration information, version.
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Soon Hwa Han et al
As a result, three templates can be generated: Referral tured Body type and was written out in the XML format. The
Form, Referral Reply, and Information Release Request. In Body encompassed items regarding lab test results, medica-
this study, lab test result, medication order and health sum- tion orders and treatment summaries and was constructed
mary are summed up into an integrated template, and repro- in accordance with the CDA standard, as shown in Figure 4.
duced into a standardized XML format. We structuralized diagnosis, injection history, and test re-
A CDA document basically consists of two parts: Header sults. In addition, we adopted ‘entry’ concept to achieve in-
and Body [7]. The former contains patient’s personal infor- teroperability between different terms that have same mean-
mation and the latter contains medical information. ings, so that the loss of information is reduced, and the value
In this study, the CDA Body was constructed in the Struc- of information is raised [8]. More details are mentioned in 4.
Figure 4. Clinical document extensible markup language (XML) format for diagnosis applying clinical document architecture (CDA)
standard.
Figure 5. Document registry frame-
work (DRF). CDA: clinical
document architecture.
284 www.e-hir.org doi: 10.4258/hir.2010.16.4.281
Implementation of MIES Based on EHR Standard
Application of Standard Terminology. module in order to be applied to various platforms easily.
The system in this study was developed on ".NET" platform,
3. Application Methodology of Data Transfer and the API was applied by using the "Visual studio .net."
The Document Registry Framework (DRF) suggested by
CIEHR of Korea is used to connect the Registry Server, which
registers and manages information categories subject to ex- 4. Application of Standard Terminology
change, and the Repository, which stores and manages the Since a standardized terminology needs to be employed to
CDA documents (Figure 5). transfer information of a diagnosis and medication from
A CDA document is stored at the Repository upon cre- different systems, the code for the standardized terminol-
ation, and registration information is stored at the Registry ogy was adopted. The description of the standard code was
in the form of a message. To retrieve the generated CDA made into CDA Entry level. To notate the diagnosis of a
document, the Document Consumer obtains the CDA ID patient, ICD-10 codes were used and marked into the Entry
and information on the location of the Repository from the in a CDA document. The medication was represented in the
Registry, and finally gets the CDA document through ebX- Entry level of CDA document by using the main ingredient
ML. electronic data interchange (EDI) codes.
The DRF was provided in the format of Web service defini- For diagnosis code ICD-10, the codeSystem sets 2.16.840.1.
tion language (WSDL) along with the API of a transmitting 113883.6.3 at the Entry Observation (Figure 6).
Figure 6. Example of applying standard terminology to diagnosis.
Figure 7. Example of applying standard terminology to medication.
Vol. 16 • No. 4 • December 2010 www.e-hir.org 285
Soon Hwa Han et al
The EDI code for medication is employed without alterna- The meta-information contains data of the sending and
tion and the codeSystem is set for 2.16.410.1.10000.4, along receiving medical institutions, medical staff in charge, res-
with the information on ingredients, dosages and manufac- ervations, diagnosis and meta ID. Especially, the meta ID is
turers of the drugs in use (Figure 7). transmitted as a message produced by the OID rules. This
OID is unique to each message, and serves as an index to
5. Application of Security search the relevant CDA document [9,10]
The security guidelines proposed by the CIEHR of Korea When receiving a message, it is delivered via the Web Ser-
was used to ensure the information security. In this study, we vice which known as the CDARegService. This web service
aimed at building essential security systems for implementa- uses the message decryption for decoding, and uses the mes-
tion of online services, such as encryption in the communi- sage parser for interpretation, and stores the meta data to the
cation section, server security, and database security, protec- database.
tion against hacking, contents and network security.
For this purpose, the VPN was implemented to encode 2) Information exchange registry service
packet in each middleware section. To protect the database For patient or hospital to subscribe this service, it needs to
and the server, an encryption solution was applied. A web sign up for the service at the MIES Server for certification.
firewall was installed to protect hacking. Especially, to secure The registration procedure is provided by Web Service at the
the data, all the transmitted data were sent out after encod- EHR Registry Server. The procedure is tailored for the each
ing and decoded after receiving by using public-key cryptog- stage of information exchange, and contains information on
raphy. Referral, Reply, and Request. In addition, two other services
The communication through the Web Service mounted on are provided: one that verifies the consent to the release of
the middleware is conducted by managing the certification the medical information, and the other that stores the regis-
codes for the middleware of each hospital so the access to try information. The fields managed by Registry Server are
the service is blocked if certification failed. shown in Table 1.
When sending a message, each packet is encoded for trans- A certification message in a XML format is sent out, which
mission within VPN-controlled section. As the message activates the Registry Service from the MIES Server. The
calls the Web Service on the Registry Server; the paging
call is verified against the Web Service Security Enhanced
(WSE) for passage. Also, the Token in SOAP-type is checked Table 1. Registry information type & description
for verification. Specifically, the ID and the password are Field name Field description
checked. The password is encoded and stored in the database
REG_HOS_ID Electronic health record agree institu-
for verification. Finally, after certification, the encoded mes-
tion code
sage is decoded and delivered to the final recipient.
REG_ID Patient identifier
Furthermore, access control was accomplished by monitor-
REG_PT_NM Patient name
ing user’s IP and Mac address on internal network in the
REG_PT_SSNID Patient social number
security policy.
SND_HOS_CODE ‘Refer in’ hospital code
SND_DEPT_CODE ‘Refer in’ hospital department code
III. Results
SND_DEPT_NM ‘Refer in’ hospital department name
1. Registry Server SND_DR_NM ‘Refer in’ doctor name
The Registry Server stores meta-information for exchanging RCV_HOS_CODE ‘Refer out’ hospital code
the patient’s medical information to referral. It provides two RCV _DEPT_CODE ‘Refer out’ hospital department code
types of services: messaging service which facilitates sending RCV _DEPT_NM ‘Refer out’ hospital department name
and receiving the meta-information, and the registry service RCV _DR_NM ‘Refer out’ doctor name
which registers and manages information on exchange.
RSV_HOPE_DATE Reservation date
META_ID Clinical document architecture docu-
1) Messaging service
ment identifier
The messaging service is composed of the services of storing
DIAGNOSIS_CODE Diagnosis code
and inquiring the transmitted message. When transmitted,
DIAGNOSIS_NM Diagnosis name
each message is made in the XML format.
286 www.e-hir.org doi: 10.4258/hir.2010.16.4.281
Implementation of MIES Based on EHR Standard
final authentication undergoes the processes such as verifica- istry Server and the CDA document is stored at the CDA
tion of consent, certification and EHR registration. The cer- Repository. To transmit the stored CDA document, the
tification message conveys the information on the ID code Transfer Server searches the CDA documents produced at
of the medical institution and the patient's social security the requesting institution or the receiving institution, and
number. These two pieces of information are used to check sends the relevant information to the requesting institutions.
whether the EHR registration has been done or not. During To search a document stored at the CDA Repository of the
transmission, the certification information is encrypted. hospital, the unique index of the document is required to
When the consent information is absent, the Registry Web facilitate this process. Thus, a unique ID is assigned to each
Service sends an "Authentication Fail" message to the origi- CDA document, and the unique ID is transferred as the
nal sender. Upon receiving it, the sender sends back the meta ID upon message transmission.
registry information. When the registry information arrives When requesting for transfer of a CDA document, the re-
at the MIES Server, its Registry Service activates and regis- questing hospital sends to the requested hospital, the OID
ters the information. Once the information on the patient generated from the messaging Web Service. The link service,
and the hospital are registered, the Registry Service sends an which searches the CDA record, is registered at the registry
"Authentication Success" message to the original sender, and through the CDA Search Service, and the CDA Document is
the sender is now able to access the information exchange stored at the CDA Repository.
service and start the medical information exchange process. The requested hospital finds out the location in the Registry
in reference to the meta ID of the received message. Upon
2. CDA Transfer Server receipt of the request, the DRF Server searches the indexed
When a hospital transfers patient to another institution, the document stored at the CDA Repository by the meta ID and
requesting institutions send a referral message to the Reg- transfers to the requested hospital.
Figure 8. Clinical document architecture (CDA) Viewer.
Vol. 16 • No. 4 • December 2010 www.e-hir.org 287
Soon Hwa Han et al
Table 2. Comparison of the prototype of the information exchange system and the MIES
Subject Prototype of information exchange system MIES (System based on EHR standard)
Subject institution Clinics, secondary hospitals (SNUBH) Clinics, secondary hospitals (SNUBH)
No. of affiliated clinics 9 33
No. of cases Appr. 1250 (2007.07.19 - 2008.6.20) Appr. 5100 (2008.06.21 - 2009.03.20)
Information exchanged Diagnosis, medication orders, lab test result Diagnosis, medication orders, lab test result, surgery
history, and medical images
Documents exchanged Medical referral and reply form Lab, medication, health summary medical referral and
reply form, request for release of medical information
CDA level CDA R2 without entry CDA R2 with entry
Standard terminology No applicable codes - Diagnosis: ICD-10
- Medication: EDIcode
- Item definition: LOINC
Parties of exchange One-to-one exchange via gateway between One-to-many exchange via EHR registry server
hospitals
Transmission method Web service Web service (message) & ebXML (CDA)
Encryption Secret key cryptography Public-key cryptography
Platform .NET .NET & JAVA
Security SSL, server vaccine, and firewall Encryption in the communication section, server
security, database security, protection against web
attacks, content security and network security,
SSL implementation of VPN
MIES: medical information exchange system, EHR: electronic health record, SNUBH: Seoul National University Bundang Hospital,
CDA: clinical document architecture, SSL: secure socket layer, VPN: virtual private network.
CDA Transfer Server separately in order to divide patient
3. CDA Viewer information and medical information. The Registry Server
When a hospital or a clinic refers or replies to another insti- contains the patient profile and the indexes of the medical
tution, including medication information, LAB test results information only. Therefore it is possible to reduce the bur-
and the patient profiles the CDA document is generated. den arising from management of the entire medical data.
The requesting hospital needs a program to make the CDA Each CDA document is maintained in the CDA Repository
document, CDA generator. Also, to see the CDA document, of each medical institution.
you need the CDA viewer which changes the CDA docu- The interaction between heterogeneous systems became
ment into the document applied XML Style Sheet (XSLT) possible by using middleware. Since MIES was constructed
(Figure 8). based on the exchange standard suggested by CIEHR of Ko-
rea, any system can be accessed.
IV. Discussion Table 2 shows comparison of the old “Prototype of the
Information Exchange System” and the new “MIES” devel-
We developed a CDA standard-based medical information oped in this study. The “Prototype of Information Exchange
exchange system which electronically exchanges the medi- System” was implemented to check possibility of medical
cal information items defined in accordance with the CDA information exchange between nearby several clinics and
document standard, adopting the standard transmission SNUBH.
method and security devices. The security and standardiza- Currently, there’s a lot of Hospital’s demand to adopt this
tion approaches covered all processes. instant system for effective information exchange in Korea.
To provide the better protection and security of the patient’s To meet these demands, following study must be pursued to
information, the MIES established a Registry Server and a build an advanced system enabling information exchange
288 www.e-hir.org doi: 10.4258/hir.2010.16.4.281
Implementation of MIES Based on EHR Standard
between multiple Hospitals and clinics. 4. Kim Y, Cho IS, Seo JW, Kim IK, Kim HG, Choi Y. Re-
By applying international standards to exchange of infor- search and development efforts aimed at implementing
mation between different medical information systems, this electronic health record systems with interoperability
study will expectedly contribute to medical information ex- and patient safety. J Korean Soc Med Inform 2006; 12:
change not only between domestic medical institutions, but 115-132.
also international medical institutions. 5. Sartipi K. Yarmand MH. Standard-based data and ser-
vice interoperability in eHealth systems. This paper
Conflict of Interest
presented at IEEE International Conference on Software
No potential conflict of interest to this article was reported. Maintenance 2008; 2008 Sep 28 - Oct 4; Beijing, China.
6. Haomin L, Huilong D, Xudong L, Zhengxing H. A clini-
cal document repository for CDA documents. In: Pro-
Acknowledgements
ceedings of ICBBE 2007: Bioinformatics and Biomedical
This study was sponsored by the Ministry of Health & Wel- Engineering; 2007 July 6-8; Wuhan, China. p1084-1087.
fare of Korea (Assignment No.: A050909). 7. Health Level Seven International. Clinical Document
Architecture [Internet]. Ann Arbor, MI: Health Level
Seven International; c2007-2010 [cited at 2010 Aug 3].
References
Available from: http://www.hl7.org.
1. Kim NH, Kim HR, Nah JY, Choi HJ, Lee HR, Jung HJ, 8. Yun JH. Generation and processing of CDA documents
Choi MR. Designing electronic medical record using based on entry level supporting templates [dissertation].
health level 7 development framework. J Korean Soc Deagu: Kyungbuk National University; 2008. p116.
Med Inform 2005; 11: 273-278. 9. Health Level Seven International. Object identifier
2. Park SH, Bom HS. A web-based medical information (OID) registry [Internet]. Ann Arbor, MI: Health Level
exchange system using HL7 protocols. J Korean Soc Seven International; c2007-2010 [cited at 2010 Aug 3].
Med Inform 2002; 8: 11-16. Available from: http://www.hl7.org/oid/index.cfm.
3. Center for Interoperable EHR. EHR. Seoul: Center for 10. France telecome. Object identifier(OID) repository [In-
Interoperable EHR; c2008- [cited at 2010 Dec 15]. Avail- ternet]. Paris: France telecom; c2010 [cited at 2010 Aug
able from: http://www.ehrkorea.org/. 3]. Available from: http://www.oid-info.com.
Vol. 16 • No. 4 • December 2010 www.e-hir.org 289
