EMR standards in cardiological outpatient management

From 1997 a hospital informative system (HIS) has been established in our institute for clinical data management and proprietary protocols have been adopted for data exchange. In the outpatient setting standardization for direct integration with other subsystems is mandatory due to huge clinical and administrative data amounts. Aim of this study was to standardize a common informative system using HL7-CDA rel.2 protocol as data interface exchange among different outpatient specialties. An interaction model was produced and compared with a draft version of HL7 CDA version 2; structured data were superimposed to the basic CDA skeleton. The structured body was extended with clinical information coded with LOINC and SNOMED dictionary. This system was able to set a CDA packet containing visit reports and relevant clinical information, sharing data with other specialties through a central repository.