Jan 18, 2021
Standard for Electronic Doctor's Letter
HL7 voting procedure for the "psychosomatic-psychotherapeutic or psychotraumatological doctor's letter" successfully completed
The ERDF-funded project Telemedical Network Psychotraumatology Saxony (Tele-NePS) develops telemedical solutions that greatly facilitate the work of psychosomatic-psychotherapeutic and psychotraumatological clinics, especially trauma outpatient clinics according to the Victim Compensation Act. This also enables more efficient counseling and therapy at the highest level for patients with trauma sequelae—regardless of their place of residence and treatment. The Saxon project partners have now submitted the specification for a standardized electronic doctor's letter to the HL7 Germany voting procedure and successfully completed it.
Within the framework of the ERDF project Tele-NePS, the project partners of the Clinic and Polyclinic for Psychotherapy and Psychosomatics at the University Hospital Dresden, the Chair of Business Informatics, esp. Systems Engineering at the TU Dresden and the Carus Consilium Sachsen GmbH have developed a specification based on the Clinical Document Architecture (CDA) for a standardized psychosomatic-psychotherapeutic or psychotraumatological doctor's letter. The CDA represents an IT standard that translates clinical documents into the language of computer systems and thus enables, among other things, cross-clinic communication between different technical systems and can reduce multiple documentation. The new physician's letter is essentially based on the specification work of the physician's letter named ‘Plus’ and expands it to include specialist psychosomatic documentation content. This now also covers the broad spectrum of psychosomatic-psychotherapeutic findings and treatment conditions.
This is particularly relevant since trauma sequelae show a high comorbidity with other mental disorders as well as physical illnesses. The specification is designed in such a way that individual modules of the doctor's letter can be compiled as required, e.g. as a purely psychotraumatological doctor's letter as well as a report of findings for any other mental disorder. A doctor's letter created in this way contains medically and psychotherapeutically relevant information and is intended for data-protected transmission between health care providers who have been authorized to do so by the patient.
In order to ensure that as many psychosomatic and psychotherapeutic institutions as possible see their requirements for this electronic doctor's letter mapped, a coordination process has been taking place within the HL7 clinical and technical expert community since the beginning of October 2020. HL7 is a consortium that develops digital standards for healthcare. Once again, special thanks are due to the participants in this landmark voting process in the context of the digital patient record.
The implementation guide with background information on the Tele-NePS project as well as the structure, content and technical specification of the doctor's letter can be found at the following links:
The project is supported by funds of the European Regional Development Fund (ERDF) and the State of Saxony.
