Publiceret: 5/11/2009
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Applied Information Technology Laboratory, Sao Paulo State University Open XML Formats Simplify Digital Exchange of Health Information in Brazil

The Applied Information Technology Laboratory at the São Paulo State University (UnESP ), Brazil, conducts technology research projects. The lab helped doctors comply with a new XML-based standard for exchanging health data over the Internet. Researchers used Open XML Formats to embed the mandated XML schema compliant data into a form using Microsoft® Office Word 2007. Now doctors can fill out the form while simultaneously complying with the new standard.


Business Needs

Founded in 1995, the Laboratório de Tecnologia de Informação Aplicada (LTIA, or Applied Information Technology Laboratory) at São Paulo State University (UnESP) in Brazil fosters research projects that seek to translate technology innovation into solutions with real-world applications.

Leandro Goulart, Master of Information Technology Student at São Paulo State University, Daniel Assad, Researcher at the Applied Information Technology Laboratory, and Eduardo Morgado, Ph.D., LTIA Coordinator, are working on one such project, which aims to facilitate the exchange of medical and financial information between doctors and health insurance companies. Until recently, doctors printed and completed health forms and invoices and mailed them to the payer. This caused payment delays and added an element of risk to the exchange of private health information. Doctors had to track payer’s different forms and invoicing processes.

To introduce efficiencies into this system, the Agência Nacional de Saúde Suplementar (ANS, or National Agency of Supplemental Health) recently established a single standard for information exchange among health providers and health insurance companies. Called Troca de Informação em Saúde Suplementar (TISS, or Supplementary Health Information Exchange), this standard is XML-based.    

“At first, doctors were encouraged to open the template, fill it out, and mail it to the insurers,” says Goulart. “Now, the ANS wants everyone to exchange the information digitally. This was a problem for independent practitioners and small clinics, many of whom practice in isolated places and do not have an information system compliant with TISS. We saw an opportunity for a new research project: to explore how XML-based digital documents can help doctors exchange documents and be compliant with the TISS XML-based schema. We wanted to build a solution to help these health providers comply with the ANS directive.”


Goulart and Assad built an Office Business Application (OBA) called DocTISS. OBAs use the client, servers, and services available in the 2007 Microsoft® Office system and can be applied to Web-based processes, such as the exchange of documents over the Internet. Goulart and Assad envisioned an OBA that would facilitate the digital exchange of health information using Web Services. 

* It is because DocTISS is based on Open XML Formats that it can be readily used by any doctor in Brazil working within the familiar Microsoft Office document authoring environment. *
Leandro Goulart
Master of Information Technology Student, São Paulo State University

The research team needed to integrate the TISS schema into a Microsoft® Office Word 2007 document so doctors could fill out a form in a familiar authoring environment, while at the same time complying with the TISS standard.

Goulart and Assad knew the solution lay in the Open XML Formats common to Office 2007 programs. Open XML Formats documents contain a collection of parts wrapped in an industry-standard ZIP container, a popular data compression and archival format. “Thanks to the modularity of the Open XML Formats, we can compile an Office Word 2007 document that looks exactly like the ANS template,” says Goulart. “We then embedded the TISS XML schema that ANS mandated into the Open XML in Office Word 2007 so that it’s hidden from the user.”

“After completing the form, the physician clicks a button to send the document to the health insurers and then the OBA comes into play,” continues Assad. “DocTISS extracts the TISS XML document out of the Office Word 2007 file and sends it via Web Services to the insurers, who are already familiar with the standard. This way we are complying with the ANS mandate that says you have to use the TISS standard for the actual transmission of the data.”

The research laboratory released the first iteration of DocTISS in February 2009. It is available for download on the Microsoft open source community Web site, CodePlex, ( In the month since launch, more than 500 people have downloaded DocTISS.


Researchers at the Applied Information Technology Laboratory used Open XML Formats to create a practical solution for health practitioners across Brazil.  “It is because DocTISS is based on Open XML Formats that it can be readily used by any doctor in Brazil working within the familiar Microsoft Office document authoring environment,” says Goulart. “This project boosts our competency in delivering Open XML solutions with real-world value.”   

Goulart and Assad took advantage of several new benefits offered by Open XML to create DocTISS: 

  • Flexible: The TISS XML schema was developed by the ANS for secure data exchange over the Internet, yet the research team could easily include it in the Office Word 2007 document they wanted to offer the doctors. “We were able to integrate the TISS schema because Open XML enables rapid assembly of documents using parts from disparate sources,” says Assad.

  • Open and royalty free: Open XML Formats and ZIP technologies are universally accessible, a crucial trait in a solution that aims to standardize a nationwide health protocol. “Any doctor can exchange health and financial information with any insurer, as long as they use an application that supports reading and writing TISS XML documents,” says Assad.

  • Robust. Open XML Formats are more robust than the binary formats, reducing the risk of lost health information due to damaged or corrupted files. The new file formats segment and separately store each part of a file package, so even if one file part is corrupt, the remainder is still available for the doctors or health insurers to access.

  • Efficient. “We reduced DocTISS files by 40 percent, thanks to the ZIP compression technology for Open XML,” says Assad. “This is big help for doctors storing all their files on a single office computer. More efficient electronic transfer also means they get paid more quickly.”

  • Security-Enhanced. Open XML provides an extensive environment for signing documents using a digital signature so that Goulart and Assad could ensure compliance with the TISS standard.
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In the Applied Information Technology Laboratory at the São Paulo State University in Brazil, both students and instructors design real-world applications using leading edge technology.

Software & Services
  • Open XML Format Software Development Kit
  • Microsoft Office Word 2007
  • Office Business Applications

IT Services