Frequently Asked Questions


Kmehr-Bis does not answer all my questions and does not address all my dreams. Is this normal ?
Yes, this is normal ! Kmehr Bis does not aim to standardize all medical matters in all ways. Our mission is to propose an immediately usable XML format to exchange key medical transactions in Belgium. HL7/CEN/ISO should propose such exhaustive standards in the coming years. We follow their activities and more particularly the HL7 CDA specification. We are sure that it will be easy in the future to convert our format to those standards using simple XSL-T.
Kmehr-Bis does not ensure the message management like physical delivery and acknowledgment. Is this normal ?
Yes it is ! Kmehr-Bis is not responsible for the message management.
Kmehr-Bis defines the structure for the exchange of medical information. This includes the identification of the sender, the recipients, required acknowledgment or urgency for delivery. It is the responsibility of certified IT systems to ensure that the specification for the distribution of the message are effectively implemented. This could be a key role for the S3 project.
Kmehr-Bis does not ensure the confidentiality of the message. Is this normal ?
Yes it is ! Kmehr-Bis is not responsible for the message management.
Kmehr-Bis defines the structure for the exchange of medical information. This includes a facility to specify a list of individuals/departments/organisations that are exclusively allowed to consult a part of the message. It is the responsibility of certified IT systems to ensure that the wishes for confidentiality expressed in the message are effectively implemented. In the same way, the encrypting of the message when transported or stored is an issue for implementing systems that should comply with the recommendations of the working group security.
What should I do if the recipient is not identified ? For example, when I prescribe a pharmaceutical product, I do not know where the patient will catch the product.
A recipient is always mandatory for a Kmehr message. When you do not know which individual person will receive the message you must at least specify the organisation that will temporarily host the message and ensure its later distribution (the organisation managing a regional server for example (S3)).

You can then make use of the confidentiality element to restrict the access to particular transactions or items.

What should I do if I do not have an ID-HCPARTY for a performer of an examination ?
It is possible that a healthcare party has no RIZIV/INAMI number (no ID-HCPARTY). Some 'medical' specialties or 'medical' acts are indeed not officially recognised by the RIZIV/INAMI. In that case, you must place an empty <id S="ID-HCPARTY" SV="1.0"/> element to signify explicitly that the hcparty has no RIZIV/INAMI number. This indicates that it was not an omission. You can then add an alternative id of your choice (SIS card number, identity card number, BTW/TVA number, ...), like <id S="LOCAL" SL="BTW" SV="1.0">BE1234567890</id>. This applies also to organisations.

Certified IT systems are not obliged but could do the matching of healthcare party using your alternate id or firstname/familyname/address. There is a possibility of rejection of your message.

What should I do if I do not know the ID-PATIENT ?
It is possible that you do not know the ID-PATIENT of your patient. In that case, you must place an empty <id S="ID-PATIENT" SV="1.0"/> element to signify explicitly that you did not know it. This indicates that it was not an omission. You can then add an alternative id of your choice (identity card number, the patient number within your system, ...), like <id S="LOCAL" SL="MyPatientNumber" SV="1.0">1234567890</id>.

Certified IT systems are not obliged but could do the matching of patient using your alternate id or firstname/familyname/sex/birthdate/address. There is a possibility of rejection of your message.

I was so happy with my simple ASCII delimited file. Why should I now spend time on that esoteric XML structure ?
What is simple for you looks probably complex for others (like XML for you). Kmehr-Bis introduces a new standard that should cover multiple domains of the Belgian healthcare communication.

The XML technology has been chosen because:

  • it is THE worldwide standard for message exchange on the internet
  • all current initiatives for healthcare message standardisations are based on a similar XML structure
  • XML is really platform independent
  • XML helps your programmers/application providers because it comes with many web standard facilities:
    • XSchema which is a file where we define the constraints on the structure. All modern software development tools can take benefit of this facility to validate the Kmehr message, referring to the validating web site.
    • XSL which is a file that can transform your XML file into a pretty document that you can browse or print. A simple standard viewer for Kmehr message can be placed on any web site or local workstation.
    • XQL which is a query language facility that will allow to search structured data within XML files.
    • SOAP and its webservices to communicate with medical web servers.
  • XML is self-describing. Usually to understand an ASCII file like a HL7 message, you need to refer to a specification document. Within the Kmehr message each data is written within a tag that expresses explicitly its meaning. Also codes are usually meaningful. This means that the Kmehr message is relatively human readable. This reduces the learning curve for newcomers in the world of healthcare message exchange.

    Also because it is self-describing, the message is a good candidate for long-term archive of structured medical document. In that case, the meaning of each code should be stored systematically within the message.

OK, but we were using powerful coding systems we were all happy with in our region. Are they lost ?
No. It is possible to remain full Kmehr-Bis compatible while still using your own codes.

Kmehr-Bis proposes simple reference tables to ensure a minimal normalisation of Belgian healthcare communication. Beside the mandatory national code, you can always associate your own code.

Lets take an example:
KHMER-BIS proposes the RCM/MKG values for discharge type. If you also want to transfer a more detailed code just do the following:
<item>
  <id S="ID-KMEHR" SV="1.0">7</id>
  <cd S="CD-ITEM" SV="1.0">discharge</cd>
  <content>
    <cd S="CD-MKG-DISCHARGE" SV="1.0">2</cd> the official code
    <cd S="LOCAL" SL="MyDischargeCodes" SV="3.2" DN="Sortie Exigée non signée" L="fr">SENS</cd> your code
  </content>
</item>

If the recipient does not know your coding system, she/he will at least recognise the national one and she/he can take benefit of the text description that you have to provide in the DN attribute.

OK, but finally the file will be much bigger than my delimited ASCII file.
Indeed, the benefits of XML have to be paid by an increased file size.

While elaborating the Kmehr message, it has systematically be decided to give priority to readability rather that sparing bytes.

Because internet connections evolve to permanent lines (ADSL/cable) we can expect that this increase of size will be acceptable in terms of performance.

Nevertheless, if your traffic is paid in relation with the size of the files, the following options must be considered:

  • compress the file before sending and after receiving: XML files have a high rate of compressibility
  • in addition to that it is easy to apply a bi-directional XSL-T that would dramatically reduce the size of the file even before compression. That XSL-T would substitute the long element and attribute names by very short ones. I give an example: You can substitute the following Kmehr sequence

    <transaction><id S="ID-KMEHR" SV="1.0">3</id><cd S="CD-TRANSACTION" SV="1.0">pharmaceuticalprescription</cd> ... </transaction>
    by
    <pp i="3">...</pp>

    By this mechanism 124 characters are replaced by 15.

    The XSL-T has to be applied before sending and after receiving. It is very easy to write.

    We invite you to choose a message operating company that would adopt such a strategy to dramatically reduce the impact of the XML technology on the file size.

  • and finally we recommend you to send your text as a Kmehr message rather than through a big Word document. This will be smaller and bring much more value to the recipient.
How can I associate a Word document or an image to a Kmehr message ?
Kmehr-Bis has foreseen the possibility to embed any multimedia object within the XML file itself. Therefore you have to use the lnk element.
To specify that the object is encapsulated within the lnk element itself, you have to specify an empty URL:
<lnk TYPE="multimedia" MEDIATYPE="application/msword" URL="">...your word file as binary data...</lnk>

It is also possible to specify that the object is located on a remote web server:
<lnk TYPE="multimedia" MEDIATYPE="image/jpeg" URL="http://www.s3.org/document-number.jpg"/>
In that case the content of the lnk element is empty.

How can I visualise an encapsulated object ?
The Kmehr-Bis format can be visualised without any program on your PC, just making reference to the XSL that is available on the support site. But, that XSL can not visualise all encapsulated data.

Today, the XSL technology only allows to visualise encapsulated images. To visualise other media types (Word, sound, ...) you need to extract the encapsulated object from the XML and then call the appropriate browser.

We can expect that standard tools will appear on the market in a near future with the maturation of the Xlink specification.

The Kmehr-Bis support site could also propose a webservice that supports such facility...

When should we expect that Kmehr-Bis becomes a standard ?
Part of Kmehr-Bis should be required for the labelling of gp software in 2003.
We can expect that full support will be required in 2004.
What do you mean by certified IT system ?
It is the intention that GP software as well as hospital and organisation's Information Systems will be labelled 'conformant' with the Belgian Ministry of Health recommendations. In addition to the Kmehr structure, additional criteria will be added; covering encrypting, authentication, recovery, ... issues.
Does Kmehr-Bis mean the disparition of message operating solutions like Medibridge, Mexi, ... ?
Combined with the usage of a national PKI, Kmehr-Bis will enable direct structured communication outside of such solutions.

Nevertheless, those solutions can still bring added value on:

  • message management: compression, acknowledgement, resend, ...
  • user management: support, training
  • dictionary management: automatic update of reference tables, mapping of your local codes
We invite you to check if your operator is preparing itself for the revolution !
How can I validate my XML message ?
Just add the following line as the second line of your XML:
  • <?xml:stylesheet type='text/xsl' href='http://www.chu-charleroi.be/kmehr/xsl/kmehr.xslt' ?>
Now click on your xml file. A validation report will be displayed.
How can I visualise my XML message ?
Just add the following line as the second line of your XML:
  • <?xml:stylesheet type='text/xsl' href='http://www.chu-charleroi.be/kmehr/xsl/kmehr-en.xsl' ?>
Now click on your xml file, it should look totally differently !
I get troubles with the Kmehr-Bis web site.
This site by definition includes many XML/XSL/XSD files. To render those files normally, your web browser must be XML enabled. This is the case for Microsoft IE 5.5 and later versions.
If you do not use a Microsoft browser, do no try the last option of the XSL demonstration section. You should swap from one XSL to another manually !

Let me know your problems with this site.

Thanks,
André