Standards: Records Guidelines for E-Healthcare

When was the last time you visited your doctor? Rather than lecturing you on the need to visit your doctor regularly (you should), in this column, I’ll discuss some of the standards that help health practitioners to better manage the information they gather about you as their patient. Increasingly, doctors are now coming into the examination room toting a laptop. Through this laptop, they now have access to all the health records about the patient and can use it to add updates. It is also an excellent tool for reminding the doctor of routine tests that should be scheduled to help the patient maintain good health. In many cases, the doctor is also using secure Internet sites to post health test results and records to keep the patient informed.

While having health information on the Web is good, it does not help when a parent has to complete the forms for a child to participate in a sports program or if a person moves or travels. When you move to a new city and have to start with a new doctor, it is important to transfer your health records from the old doctor to the new doctor so that the new doctor is aware of the existing conditions and treatments that are prescribed. If you travel either on leisure or business, getting sick or hurt is usually not a top-of-mind concern. However, should the unfortunate happen, How can you assure that you are receiving the appropriate critical care that you need?

Wouldn’t it be wonderful if you had all of your health records, lab results, x-rays, etc., on a thumb drive or other small device that you carried with you? In having health records in electronic format, protecting the records is critical.

In 2006, AIIM along with ASTM International (a standards-making body), initiated a project to provide guidance as to how the PDF (Portable Document Format) file format could be used in healthcare. A committee was formed that consisted of representatives from all areas of the healthcare industry and representatives from medical organizations and associations. The committee determined that they wanted to develop a best practices guide on the use of PDF rather than a standard. The resulting document, AIIM/ASTM BP1-2008, Portable Document Format in Healthcare: A Best Practices Guide, was developed to describe the features and functions of PDF that are best used in the healthcare industry. The guide is a reference tool for defining PDF as an electronic container by which healthcare information can be captured, exchanged, preserved, and protected for patients (consumers), care providers, and others in the healthcare industry.

PDF is an established file format used for information exchange in almost all industries. Because of its wide adoption and acceptance, PDF can support the capture of healthcare information that typically includes structured data, text, graphics, images, and multimedia. Given that PDF is an open standard, it made sense to propose it for use in the healthcare industry to promote the sharing of information between healthcare institutions. PDF makes it easy for healthcare professionals to use, share, and exchange health records throughout the healthcare cycle. Interoperability in healthcare is promoted through the use of PDF.

In developing the Best Practices Guide, the PDF in Healthcare committee worked to resolve many issues facing the healthcare industry including:

• Improving patient safety while lowering costs
• Sending and/or receiving paper-based health records
• Need for a universal container to hold the various types of health information
• Need of patients to access their personal healthcare information at any time or from anywhere
• Security and liability
• Ease of use

The committee recognized that errors and unnecessary expenses occur during the exchange of patient-related information between and among physicians and institutions. It takes time to transfer and search paper-based records. The committee also recognized that today’s patients want to take a more active role in the management of their healthcare.

Properly-defined PDF forms can be used in conjunction with healthcare industry XML standards such as HL7’s CDA (Clinical Document Architecture) and ASTM’s CCR (Continuity of Care Record) to provide automatic data validation and a high degree of process automation. Applications specifically designed for PDF forms development lend themselves well to the precision layout requirements of forms. The first use case example will be based on the CCR standard and will include the following:

• patient demographics
• insurance information
• problems and diagnoses
• medication list
• allergies
• immunizations
• actors, such as information about primary care physicians (PCPs), or specialists

PDF in Healthcare applications are intended to accelerate XML-based healthcare standards by providing a widely supported format for visual presentation, security, and portability for XML-based healthcare data. While there are many ways to build applications around XML standards, PDF documents provide the ability to contain both XML data and a visual representation of that data within a single file format. The use of XML standards-based PDF does not impair data interoperability with other XMLbased systems and it provides a method of presenting, transferring, interacting with, and securing healthcare information.

This Best Practices Guide discusses how PDF used in healthcare can leverage the existing standards and any future standards that may be developed. Existing standards include the ASTM Standard Specification for the CCR and the Health Level Seven (HL7) CDA. Both of these standards represent collections of clinical data as either a dataset (CCR) or as a document (CDA), which can be used in an XFA-based PDF.

As a companion to the Best Practices Guide, the committee also developed an Implementation Guide for Portable Document Format in Healthcare that provides examples of potential implementations for PDF in healthcare. This guide was developed to serve as an example of implementations of PDF in the healthcare industry. To accompany the Implementation Guide, several tools and examples have been posted to the AIIM website at http://www.aiim.org/pdfh/ig.

--Betsy Fanning (bfanning@aiim.org) is director, Standards and Content for AIIM .

PDF Standard - Approved In January 2007, Adobe Systems announced they were releasing their Portable Document Format (PDF) specification to ANSI and AIIM for the purposes of publishing the specification as an ISO standard. The draft standard (ISO 32000) was introduced to the ISO Fast Track approval process in July 2007 with a ballot that closed in December. The result: approval with one negative. In January 2008, the first international meeting of the ISO working group developing ISO 32000 was held in Orlando. During this meeting the committee was able to positively resolve the comments from the objecting voter, which resulted in the negative vote being changed. ISO 32000 is an approved standard and will be published by ISO shortly. All future versions of ISO 32000 or the PDF standard will be developed by an ISO working group. The committee is beginning work on future revisions of ISO 32000. The following are some of the ideas the committee is discussing for future versions of ISO 32000:
3D, CAD, Engineering -Incorporate the 3D algorithm, PRC into Part 1 -Improved measurment, 3D, focus on CAD -Non-scaling ilines and patterns Document Feature -Extensions to portable collections (packages) -Hyperlinks on objects (not an area) -Use of native Unicode in PDF page content streams - Root-level dictionary of all used resources -Clarification of resourced inheritance when rendering - Associate anotations (especially comments) directly with page content -Improved file provenance and "audit trails" - Per-page metadata	Accessibility -MathML Integration -New Tag Types Color -Enable N-Colorant ICC profiles as source profiles -Output intent enhancement -Black Point Compensation -Add processing instruction for color conversion -Support for DeviceLink Profiles -Specify exacly how color has to be rendered on an output device -No more uncalibrated color in a pdf - Extend color model for better support of spot colors and overprints between spot colors (and process colors)	Architecture -Remove or improve cross-referencing via XRef table - Move to an XML-coded file -Mutliple levels of data -Support for Newspaper XML document instances and related style-sheets If you would like to contribute thoughts on the above items or have features you would like to recommend be included in a future version of ISO 32000, Document management -- Portable Document Format (PDF), please feel free to send your questions and/or recommendations to bfanning@aiim.org.