Skip to main content
February 20, 2017

Content interoperability

What if DITA could lead to better care for people with cancer? This case study shows how Scriptorium and Heretto (formerly easyDITA) worked with the American Joint Committee on Cancer (AJCC) to help give doctors faster, more targeted access to cancer staging information. This week, Scriptorium and Heretto are joining the AJCC at the Healthcare Information and Management Systems Society (HIMSS) annual healthcare IT conference as guest exhibitors.

Content interoperability: Using APIs to connect the Cancer Staging Manual to health information systems

Prepared by Jorsek LLC/Heretto and Scriptorium Publishing


The American Joint Committee on Cancer (AJCC) has historically delivered its Cancer Staging Manual as a bound reference text. However, with over 80 chapters and 1000 pages of
information, accessing specific, relevant content within the Staging Manual involved physically searching through the book. Today, with the advent of widely used health information systems, the AJCC needed to restructure the information in the manual for digital delivery.

The problem: Digitizing print reference material required manual conversion into interoperable content


Image: pixabay

The AJCC Cancer Staging Manual, now in its eighth edition, has traditionally been delivered as a book. The information in the Manual is complex and accessing it in a physical text was time-consuming. In addition, clinicians needed the ability to annotate their patient files with information found in the Staging Manual. Integrating this complex information into health information systems was the answer, however, until now the developers of these systems had to manually convert the information into digital formats, organize it, and import it into their systems. This manual process was time-consuming and potentially error-prone.

The AJCC faced three major issues with the 8th Edition:

  1. Digital delivery. Those who use the Cancer Staging Manual needed a better, faster way to access specific information. A doctor who needed to know the staging criteria for neuroendocrine tumors of the stomach, for example, had to find it in a print-based version of the Cancer Staging Manual. Instead, what if that doctor could access that information from an electronic version of the manual and have it delivered instantly? To make this possible, the manual would need to be moved from its desktop publishing-based format into a consistently tagged structure.

    It is important that users in the clinical setting are able to pull up the staging manual on screen while they complete charts, so they don’t have to search for a book or rely on memory (or a guess). If a clinician can record accurate information in real time, data collectors will not have to spend so much time combing reports for key words.

    Laura Meyer, AJCC 8th Edition Project Manager and Managing Editor, AJCC Cancer Staging Manual

  2. Interoperability with existing systems. Once the information was in a format that could be delivered digitally with proper tagging, the ability to connect that information with existing health information systems became critical.

    Most importantly, we needed a single source to share electronically with organizations that used our content for data collection. In the past, we would give them a print book and expect them to do the rest of the work to build their systems.

    Laura Meyer, AJCC

  3. Workflow modernization. Various specialist clinicians write the content for the Cancer Staging Manual, and the AJCC’s technical content team collects and publishes this information. A major consideration was ensuring that these contributors understand the reasoning behind the changes and to provide them with an authoring and review environment that was familiar and did not require specialized software or a steep learning curve.

    AJCC has quadrupled its content base from 20 to over 80 chapters, and the number of contributors from approximately 100 to 420 worldwide. We needed to centralize our content base and streamline the process by which authors reviewed and edited content.

    Laura Meyer, AJCC

The solution: Structure the content, centralize the source, connect with existing information systems

The AJCC enlisted the help of Scriptorium Publishing, a content strategy consultancy, and Heretto, a component content management system (CCMS), to implement a solution that balanced these needs.

To solve the problem of access to specific content, Scriptorium designed an information architecture for the staging manual’s unique requirements and the AJCC moved the content to Heretto, an XML-based structured content environment that would allow end-users to call information via an Application Programming Interface or API.

The result: The Cancer Staging Manual can now interface directly with health information systems via APIs

Structuring the content in the Manual and centralizing it as XML files in the Heretto database made it possible to deliver organized, properly formatted, and searchable information on cancer staging directly to existing health information systems. This greatly increases the accessibility of the information in clinical and research environments and makes possible more frequent updates and additions to the current state of cancer staging assessment.

In addition, as the AJCC moves into production of the next edition of the manual, having the information available in a centralized, standard format, while retaining familiar authoring and review interfaces, will simplify the authoring, editing, and review processes for its over 400 contributors

The CCMS is linked to our API, and the API end-users probably reap the most benefit from the system now; their content is more up-to-date than the print manuals. We plan to build more outputs that will help us move away from having to maintain separate documents.

Laura Meyer, AJCC