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J Edu Health Promot 2019,  8:99

Designing a communication protocol for acquired immunodeficiency syndrome information exchange

1 Department of Health Information Technology, School of Paramedical, Ilam University of Medical Sciences, Ilam, Iran
2 Department of Parasitology, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
3 Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

Date of Submission01-Jan-2019
Date of Acceptance15-Feb-2019
Date of Web Publication14-May-2019

Correspondence Address:
Dr. Jahangir Abdi
Department of Parasitology, School of Medicine, Ilam University of Medical Sciences, Banganjab, Ilam
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_2_19

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INTRODUCTION: Interoperability will provide similar understanding on the meaning of communicated messages to intelligent systems and their users. This feature is essential for controlling and managing contagious diseases which threaten public health, such as acquired immunodeficiency syndrome (AIDS). The aim of this study was also designing communication protocols for normalizing the content and structure of intelligent messages in order to optimize the interoperability.
MATERIALS AND METHODS: This study used a checklist to extract information content compatible with minimum data set (MDS) of AIDS. After coding information content through selected classification and nomenclature systems, the reliability and validity of codes were evaluated by external agreement method. The MindMaple software was used for mapping the information content to Systematized Nomenclature of Medicine-Clinical Terminology (SNOMED-CT) integrated codes. Finally, the Clinical Document Architecture (CDA) format was used for standard structuring of information content.
RESULTS: The information content standard format, compatible selected classification, or nomenclature system and their codes were determined for all information contents. Their corresponding codes in SNOMED-CT were structured in the form of CDA body and title.
CONCLUSION: The complex and multidimensional nature of AIDS requires the participation of multidisciplinary teams from different organizations, complex analyzes, multidimensional and complex information modeling, and maximum interoperability. In this study, the use of CDA structure along with SNOMED-CT codes is completely compatible with optimal interoperability needs for AIDS control and management.

Keywords: Acquired immunodeficiency syndrome, communication protocol, human immunodeficiency virus, minimum data set, semantic standardization, structural standardization

How to cite this article:
Shanbehzadeh M, Abdi J, Ahmadi M. Designing a communication protocol for acquired immunodeficiency syndrome information exchange. J Edu Health Promot 2019;8:99

How to cite this URL:
Shanbehzadeh M, Abdi J, Ahmadi M. Designing a communication protocol for acquired immunodeficiency syndrome information exchange. J Edu Health Promot [serial online] 2019 [cited 2020 May 27];8:99. Available from: http://www.jehp.net/text.asp?2019/8/1/99/258129

  Introduction Top

Interoperability means the capability of computer systems with heterogeneous platforms in terms of hardware, software, and networking components for effective and integrated operation in different organizations.[1],[2] The interoperability is meaningful sharing of information between systems and their users.[3] There are four types of interoperability for information systems: (1) legal interoperability, (2) functional or technical interoperability, (3) structural interoperability, and (4) semantic interoperability.[4] The information systems use four levels of interoperability to communicate. At the highest level (fourth level), the exchanged data are equally understandable by human and machine (information systems).[5] At this level of interoperability, it is very important to create normalized data structures and harmonized content standards in the form of efficient communication protocols.[5]

Information systems interoperability is one of the most important prerequisites for having a comprehensive system of monitoring and controlling community health-threatening diseases.[6] The Center for Disease and Control in the United States identified acquired immunodeficiency syndrome (AIDS), tuberculosis, and malaria as major dangers to public health.[7] Using public health information exchange (PHIE) infrastructure for controlling and managing AIDS plays an important role in improving the indicators of this disease at community level and controlling it more efficiently.[8] Adaptation and development of communication protocols for integrated transfer of public health reports at PHIE infrastructure would normalize the content and structure of information messages to improve interoperability between information systems.[9]

The communication protocols are a set of rules and guidelines which reduce the complexity of communication between nodes in a network.[10],[11] There are two main components in communication protocols: syntax (determining the structure and ordering of data bits of messages) and semantic (defining the semantic of data bits of messages).[10] Adoption of communication standards for medical documents on the Internet in order to structure information messages and using terminology mapping approach for converting scattered information content into integrated codes will provide similar understanding on exchanged messages to all platforms.[12]

The terminology mapping is a kind of standardization modeling of information messages which uses normalization of data elements in coordinated formats (usually integrated terms and codes).[12] Patra et al. aimed to create a normalized protocol for sharing the information of children with AIDS. They conducted the following stages to design a communication protocol: (1) identification of data elements of AIDS reporting (minimum data set [MDS]); (2) normalization of information content through the use of medical nomenclature systems (International Classification of Diseases (ICDs), Logical Observation Identifiers Names and Codes (LOINC); and (3) Using structural Clinical Document Architecture (CDA) standard to integrate the ordering of information content.[13]

However, this study aims to develop a communication protocol by normalize the reporting content and structure of messages to step forward in improving the interoperability between information systems which are involved in care and treatment of AIDS in various beneficiary organizations.

  Materials and Methods Top

This study was conducted in four stages: (1) extracting information content for MDS of AIDS data elements; (2) encoding content and evaluating the reliability and validity of codes; (3) normalizing information content by terminology mapping; and (4) normalizing the structure of messages through using the formats of exchanging medical information on the Internet. The MDS of AIDS data elements are already designed by researcher through using a systematic review approach in the form of three nonclinical, clinical, and supportive information categories.[14]

Collection of information content

The real information of clinical cases of patients in database of the National AIDS Organization of Iran was used to identify the information content for MDS data elements. The information was provided to researcher providing that the privacy principle is observed and the identification information will remain secret. The researcher-made checklist was used for guided extraction of information content from clinical cases of patients with AIDS based on MDS classes and data elements.

Encoding information content

In next stage, the information content was coded using selected classification or nomenclature systems (ICD, LOINC, International Classification of Functioning, Disability and Health [ICF)], Read Code Classification [RCC)], and normalized drug codes [RXNORM]). After coding, the validity and reliability of codes were evaluated through surveying two health information management specialists who had a work experience in hospital encoding unit. In this regard, the external agreement method was used to recodify the information content and compare the primary codes with secondary. The descriptive statistical tests were used to check the validity of codes and evaluate the reliability of coding.

Thesaurus mapping

After evaluating and verifying the contents encoded in selected medical classification or nomenclature systems, all scattered codes were mapped to integrated codes in SNOMED-CT were defined by mapping through Mind Maple software (Java software developer organization).

Determining the medical documents' exchange format

After normalizing information content by mapping, it was necessary to structure integrated content in the form of normal reports. The CDA standard was proposed as an optimal structural standard for transferring information in comprehensive Health Information Exchange infrastructure of Iran.[15] Therefore, all mapping contents (SNOMED-CT codes) were structured in the form of CDA body and title, and the final communication protocol was proposed.

  Results Top

The MDS was already designed by Shanbehzadeh and Ahmadi.[14] The proposed MDS was divided into three data categories includes nonclinical, clinical, and supportive with ten, six, and three data classes and 73, 63, and 24 data elements, respectively.[14] The data extraction checklist was used to collect the contents of clinical cases based on MDS data elements. The MDS-compatible information content was extracted in three nonclinical, clinical, and supportive areas. It should be noted that in order to preserve the security and confidentiality of patient information, the information content of demographic data was defined formally (unrealistically). After extracting the information content, all contents were encoded through their respective classification and nomenclature systems. The ICD10, ICF, RXNORM, LOINC, ICDs, Ninth Revision, Clinical Modification (ICD9CM), the International Classification of Health Interventions, ICD10 Procedure Coding System (ICD10-PCS), and the International Classification of Procedures in Medicine (ICPM), the Diagnostic and Statistical Manual of Mental Disorders (DSMs), and RCC were used to codify diseases and other related disorders, health conditions, drug and prescription, laboratory and evaluation findings, medical and surgical procedures, mental situation, and general and specific situation, respectively.

The evaluation of validity and reliability of codes using external agreement showed that from three information categories, 20 information classes, 68 data elements, 71 preference codes, and 68 reference codes (SNOMED-CT), there were 66 similarities between initial and secondary codes (code matching), 5 significant difference between initial and secondary codes, and 8 minor difference between primary and secondary codes. All differences between codes were ignored at decimal level. Therefore, only significant difference was the basis for evaluating the final reliability between primary and secondary codes. [Table 1] shows these differences along with the results of their final reliability assessment.
Table 1: Reliability codes assessment

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After finalizing the codes which were assigned to information content, it was necessary to provide preconditions for normalizing content through thesaurus mapping. In [Table 2], [Table 3], [Table 4], the structuring of information content is conducted based on information category, information classes, and data elements. The format of information content, type of preferred classification or nomenclature system, and corresponding codes were defined for all information contents in each of three information categories in SNOMED-CT. In addition, the code values were defined for some data elements; this integrated the definition of information content of those data elements.
Table 2: Nonclinical minimum data element description

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Table 3: Clinical minimum data element description

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Table 4: Support minimum data element description

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The SNOMED-CT National Pathology Exchange Online Browser was used to search for concepts and codes in SNOMED-CT. There were 20 conceptual categories of SNOMED-CT in this browser. The MindMaple software was used to link the information content with scattered preferred codes and terms in multiple classifications and nomenclature systems and then mapping them to integrated reference terminology (SNOMED-CT). Due to the high level of information classes in MDS, one class of medical category, one class of supportive category, and two class of clinical category were visualized as mapping paths in MindMaple Software. The name of information class, name of data element, name of information content, preferential codes, and their reference code were specified at mapping paths [Figure 1].
Figure 1: Triple mapping routes

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The general areas of mapping in this study include: (1) mapping general and specific situations to RCC codes and SNOMED-CT code; (2) mapping disease and mortality situation to ICD10 codes and SNOMED-CT code; (3) mapping nomenclature of medication to RXNORM codes and SNOMED-CT code; (4) health situation mapping to ICF codes and SNOMED-CT code; (5) mapping medical, surgical, and supportive measures to ICD9CM, ICPM, and ICD10-PCS codes and SNOMED-CT code; (6) mapping laboratory and evaluative measures to LOINC codes and SNOMED-CT code; and (7) mapping mental situation to DSM codes and SNOMED-CT code. As shown in [Figure 2], the coded information was placed around the mapping image by selected medical classification or nomenclature systems, and the integrated content was placed at the center of mapping image through SNOMED-CT.
Figure 2: Visualization of thesaurus mapping through MindMaple software

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After mapping and normalizing the information content by integrating all information contents through SNOMED-CT normal names and codes, the information exchange was structured using the most consistent normal exchange format for medical documents CDA and placement of data elements along with integrated codes which described the data elements contents; in this way, the final protocol format for transmission of AIDS information was provided. In CDA structure, the structural division is based on allocation of information content related to the identification of entities involved in care and treatment of diseases in naming of these formats and insertion of information content related to detailed information and process reports in body of documents. [Table 5] shows the CDA format for the information content of data elements in MDS.
Table 5: Clinical document architecture format for acquired immunodeficiency syndrome information exchange

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In structure of CDA, the demographic, socioeconomic, identification, and contact information classes related to identification of entities involved in AIDS care and treatment were placed at heading of documents. The body of documents included detailed information related to information classes of exposed groups, type/category of transmission of disease, pregnancy information, situation of life, information on clinical situation, diagnosis, measures and services provided to patients (surgical, prescriptive, and laboratory), background situation, and support services.

  Discussion Top

To establish an integrated and macroexchange infrastructure for AIDS management, it is necessary to meet some requirements after establishing network and communication platforms in order to make possible the communication among all stakeholders: (1) identification of data elements and designing national MDS for integrated AIDS reporting; (2) coordinate definition of information formats through functional data dictionary; (3) normalization of information content through dictionaries and medical classification systems; (4) synchronization of data flow models by mapping; (5) adoption of messenger standards for standard ordering and formatting of data elements; (6) setting reporting deadlines; (7) identifying reporter, place of submitting report, and qualified person to receive the report; and (8) determining the feedback situation of reports.[7]

In the Office of the National Coordinator for Health Information Technology report, the information exchange protocol was designed for public health conditions. The components of this protocol included: (1) designing MDS for public health reporting; (2) definition of terms' formats (code, decimal, strand, dual, textual, and numeric); and (3) predicting classification or nomenclature systems for information content normalization.[16] In this study, data synchronization was considered to be an important prerequisite for designing information exchange characteristics.[16] The author declared in this study MDS of reporting AIDS-related situations was already designed by researcher in three nonclinical, clinical, and supportive information categories in a separate study.[14] The data elements content was integrated through selected classification or nomenclature systems and mapping into SNOMED-CT content. Finally, the CDA standard was used to structure the information ordering to report AIDS conditions in the aforementioned categories.

Patra et al. designed an MDS for conducting teleconsultation with AIDS patients and tried to insert data elements related to identifying information entities (demographic information) in CDA headline and the AIDS care, ART treatment, and referrals data elements in body of CDA to integrate the message structure. Then, the information content was normalized through LOINC and ICD codes.[13] In the present study, all interoperability requirements were met through content (terminology mapping) and structural (data sorting based on CDA structure) normalization. The strength of the current research was to use mapping process to normalize the information content. The thesaurus mapping is a technical function to create information integrity through transformation of multiple terms to unified term.[17],[18] Mapping data elements may convert care documents from inactive to an active element to improve continuous and collaborative care.[19] Bouhaddou et al. showed that mapping the information content of RXNORM dictionary to SNOMED-CT creates synergy and plays an important role in integrating the concepts to evaluate drug interactions.[20]

Gordon et al. identified the information classes and data elements of personal health records of patients with AIDS and used the Continuity of Care Document (CCD) structural standard to structure the information content for transmission on the Internet. The information content was organized in two parts: CCD headline (information of entities involved in care) and CCD body (detailed information on care and clinical processes).[21] Lim et al. aimed to create a CDA format for patients with AIDS in Korea. The identification information was placed in CDA headline, and detailed information was inserted in CDA body. The SNOMED-CT and LOINC codes were used to integrate information content into CDA structure.[22] CDA supports complex and multidimensional analyses in health-care system, and CCD supports the most up-to-date and relevant patient care settings for continuing treatment. The CDA focuses on primary and secondary care objectives, and CCD supports initial care programs. The time frame for information content in CDA structure is past and present, but the CCD is related to the current clinical state of patient.[22] The present study, similar to a study of Lim et al., defined the information patterns for transmission of patients with AIDS in CDA standard format. Furthermore, the information content was normalized through SNOMED-CT codes.

Nematollahi et al. suggested that the design of MDS of AIDS along with providing disease reporting standards is important requirements for establishment of a comprehensive AIDS information management system at the national level for Iran.[23] Safdari et al. introduced the SNOMED-CT standard as the most comprehensive and most functional standard for integrating Electronic Health Record (EHR) in Iran.[24] In the present study, the SNOMED-CT standard was proposed to report AIDS-related situations in Iran. The SNOMED-CT thesaurus is recognized as a comprehensive content standard for integration of content format of terms for semantic interoperability.[25]

Tierney et al. designed the MDS of reporting AIDS in both clinical and nonclinical areas and used classification and nomenclature systems to normalize the information content of MDS data elements. For example, ICD10 was used for categorizing disease and mortality situations; the LOINC was used for naming information content related to laboratory and evaluative measures; Current Procedural Terminology was used for classifying financial and repayment measures; National Drug Code was used for coding information related to prescribing and drug therapies; and ICD10-PCS was used to normalize therapeutic procedures.[26] In this study, the systematic and structured data exchange of patients with AIDS was conducted through normalization of exchange structures of documents on the Internet using structured reports in CDA body and title.[26] The present study used selected classification and nomenclature systems to normalize the AIDS reporting data elements; finally, all contents were integrated into SNOMED-CT through mapping. Then, the data elements and SNOMED-CT codes were structured through CDA format. In both studies, standard formats were defined for content of data elements as code, free text, string, and number (pure number, decimal, and numerical textual).

Rezaie et al. aimed to create interoperability for the transmission of information in EHR in Iran. The proposed MDS was designed in two clinical and administrative information categories, eight information classes, and 85 data elements. In the headline of CDA structure, the document identification information, patient identification information, and referral information were inserted in a structured way, and in CDA's body, the information of problems and diagnosis, records, assessment and laboratory, health-care plans, and care services were provided. This study used LOINC, SNOMED-CT, ICD9, and RCC standard to normalize information content.[15] In the present study, after designing the MDS in three main clinical, nonclinical, and supportive information categories, 20 information classes, and 183 data elements, the information content of each data element was inserted in headline and body of CDA in the form of SNOMED-CT codes. Totally, this study a practical step forward into better interoperability between Public Health Information Systems. But only considered the requirements for standardization of semantic and syntax, and technical aspects for developing of communication protocol (for example: Encryption and decryption, error detection and control, scheduling, redirection and routing, marking, authentication and message synchronization) are neglected.

  Conclusion Top

The use of integrated and agreed communication protocols for the transmission of AIDS information among health and care organizations, laboratories, health organizations, management and policy-making agencies, insurance companies, and other stakeholder organizations has played a major role in improving the interoperability between information systems and collaboration between them. This requirement is very important because of complexity and multidimensional nature of AIDS.


The present article is the outcome of a PhD thesis with number 9221563207 that approved by the Iran University of Medical Sciences. Moreover, it is sponsored by the Research Deputy of the Ilam University of Medical Science.

Financial support and sponsorship

This study is financially supported by Ilam University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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