title: Clinical Document Architecture integration system to support patient referral and reply letters.
abstract: Many Clinical Document Architecture (CDA) referrals and reply documents have been accumulated for patients since the deployment of the Health Information Exchange System (HIES) in Korea. Clinical data were scattered in many CDA documents and this took too much time for physicians to read. Physicians in Korea spend only limited time per patient as insurances in Korea follow a fee-for-service model. Therefore, physicians were not allowed sufficient time for making medical decisions, and follow-up care service was hindered. To address this, we developed CDA Integration Template (CIT) and CDA Integration System (CIS) for the HIES. The clinical items included in CIT were defined reflecting the Korean Standard for CDA Referral and Reply Letters and requests by physicians. CIS integrates CDA documents of a specified patient into a single CDA document following the format of CIT. Finally, physicians were surveyed after CIT/CIS adoption, and they indicated overall satisfaction.
authors: Kyungpook National University, Republic of Korea.
authors: Sung-Hyun
authors: SH
authors: Lee
authors: Kyungpook National University, Republic of Korea.
authors: Joon Hyun
authors: JH
authors: Song
authors: Kyungpook National University, Republic of Korea ikkim@knu.ac.kr.
authors: Il Kon
authors: IK
authors: Kim
authors: Seoul National University Bundang Hospital, Republic of Korea.
authors: Jeong-Whun
authors: JW
authors: Kim
mesh_terms: D006751:Hospital Information Systems / Q000592:standards*; D006801:Humans; D008498:Medical Record Linkage / Q000379:methods / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D012017:Referral and Consultation; D056910:Republic of Korea
keywords: Clinical Document Architecture Integration System; Clinical Document Architecture Integration Template; Health Information Exchange; clinical Document Architecture; referral and reply letters