CDA-based Integration of a Teleconsultation Service into a Regional Electronic Patient Record System

Considered on a large scale, teleconsultation is even nowadays mainly understood as a communication service on a separate channel, apart from medical documentation. The results of a consultation are included in the patient record only in an indirect manner by the treating physician, usually in textual form as a consultation note. This might be reasonable as long as the consultation is performed simply by talking via phone. But if the consultation includes the preparation and communication of multimedia data (diagnostic video sequences, sounds or images) and the usage of tools like computer assisted diagnosis, then new valuable information about the patient is generated. This information should be stored and in its relevant parts be contributed to the Electronic Patient Record (EPR). Assumed, the EPR is regional (level 4 of Medical Records Institute classification [6]) and has an open CDA-based interface for referencing of information, and assumed the Teleconsultation Service (TCS) is based on CDA for storage and communication, then the TCS can be integrated in a straight-forward way by means of a dedicated TCS Document Server (TDS) and a mechanism for provision of references to the regional EPR. The concept has been worked out in the framework of a German-Finnish collaboration. Proof-of-concept is planned for beginning of 2003.