A clinician-centric medical results viewer: clinician feedback played a key roll in one not-for-profit healthcare organization's development of a web-based application for secure access, viewing and delivery of patient data, radiology images and lab results.

MedStar Health is a not-for-profit, community-based healthcare organization comprised of 25 integrated businesses, including seven major hospitals in the Baltimore/Washington area. The hospitals, which include both teaching and community facilities, are Franklin Square Hospital Center, Good Samaritan Hospital, Harbor Hospital, and Union Memorial Hospital in Baltimore; and, Georgetown University Hospital, National Rehabilitation Hospital and Washington Hospital Center in Washington. MedStar Health, like many healthcare systems, developed from a series of healthcare mergers and acquisitions. The resulting large number of healthcare applications from a variety of vendors made for a challenging environment in which to find technology solutions that would work well enterprisewide.

webAzyxxi is a Web-based clinical results viewer used by more than 2,600 clinicians to access the MedStar Health Azyxxi Clinical Data Repository, the database foundation of the Azyxxi medical information system (recently sold to Microsoft Corp.), which was created by Mark Smith, M.D. and Craig Feied, M.D. Ph.D., at MedStar Health's Washington Hospital Center and the National Institute for Medical Informatics. The Azyxxi Clinical Data Repository collects laboratory results, discharge summaries, radiology images (static and full-motion), photographic data, and all other medical data from all MedStar Health hospitals and stores it in a Microsoft SQL Server database (Figure 1). The Azyxxi data repository was designed and built in conjunction with the Azyxxi client, a traditional MS Windows client-server application.

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Evolutionary Pilot Growth

In August 2003, webAzyxxi was launched as a 200-user pilot project at Washington Hospital Center. The goals of the pilot were twofold: 1) Test Web-based remote access to MedStar clinical data; and, 2) Test the viability and security of remote access to MedStar hospital clinical data using two-factor authentication without the use of a VPN (virtual private network). The pilot was a joint project between MedStar e-Health and Washington Hospital Center Department of Informatics. This first version of webAzyxxi was created by the Washington Hospital Center Department of Informatics led by Smith and Feied. The National Institute of Medical Informatics handled the application development and refinement and e-Health was responsible for the pilot implementation.

Due to clinician demand at Washington Hospital Center, the pilot was allowed to expand beyond the initial 200 users in May 2004. Washington Hospital Center's off-site access to medical data was then supplied via an antiquated "green-screen" application. As news traveled through word-of-mouth that webAzyxxi offered an attractive alternative to the green-screen, more and more clinicians were anxious to gain access. However, with clinician demand to expand the pilot came user feedback requesting an increase in the limited data set webAzyxxi currently accessed.

The first version of webAzyxxi had a select set of medical data (e.g., labs results, patient registration data, limited images, ECGs, medications and past medical history) and clinicians were demanding more. To meet this demand, in May 2004, e-Health hired a full-time developer to expand webAzyxxi's capabilities. At that time, e-Health decided that in following their goal of clinician-centric technology, all new functionality in webAzyxxi would be developed according to a product enhancement roadmap that was largely based on clinician feedback. Both webAzyxxi's capabilities and user base rapidly expanded in 2004. Figure 2 shows the number of users over the entire history of the pilot.

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Continued Expansion

In the summer of 2004, as webAzyxxi's functionality expanded, clinicians across the MedStar enterprise began requesting that the webAzyxxi pilot expand to all MealStar Health hospitals. While webAzyxxi was capable of accessing the other MedStar Health hospital data in the Azyxxi Clinical Data Repository, webAzyxxi 1.0, which was initially designed to be a single hospital application, would require seven individual installations to support all MedStar hospitals. In the long term, maintaining seven sets of code with a three-person team would be too large a task to manage.

However, due to the demand, senior leadership within MedStar IS chose to expand webAzyxxi 1.0 to the remaining MedStar hospitals, along with all the support ramifications. While simultaneously completing the expansion, eHealth designed and built webAzyxxi 2.0 with all new functionality that would have multi-hospital support at its core. In October 2005, the last of the seven MedStar hospitals was added to the pilot, it had taken less than ten months to expand webAzyxxi 1.0 to MedStar's six additional hospitals.

In January 2006, two months after completing the webAzyxxi 1.0 expansion, webAzyxxi 2.0 was released with a completely new code set that allowed one installation to access seven different hospital data sets, resulting in a dramatic reduction in the support effort. The webAzyxxi development group consists of two full-time developers and one part-time medical database administrator. At the time of this writing, webAzyxxi has more than 2,600 users and has become the primary MedStar application for accessing patient data offsite, replacing the green-screen applications at Washington Hospital Center, as well as another vendor supplied Web-based medical results application at the MedStar Baltimore hospitals.

Security and Functionality

First Generation--webAzyxxi 1.0: The first iteration of webAzyxxi was a Microsoft ASP-based application that required the use of the Internet Explorer (IE) Web browser. The Microsoft IE requirement was due to the application code style and the USB security key Aladdin eToken, which originally only supported MS Windows when the pilot began in August 2003. The Aladdin eToken, combined with a user's password, provides two-factor authentication for webAzyxxi. To remain security device agnostic, webAzyxxi does not use any proprietary security technologies except the actual hardware device. The benefit of this design enables webAzyxxi to support additional authentication security technologies in the future.

Second Generation--webAzyxxi 2.0: The small webAzyxxi development team had to continue to add functionality to webAzyxxi 1.0 to satisfy ongoing user demand, while rebuilding the original application. As a result, all new functionality in webAzyxxi 1.0 was written in Microsoft C#, utilized Ajax as appropriate, and was built to support multiple hospitals, and to work with any modern Web browser and operating system. In this way, the mission-critical features most requested by clinicians could be added quickly to webAzyxxi 1.0 without the need to continue a code set that would not meet the long-term requirements of minimal support effort and maximum flexibility. Eventually, all existing webAzyxxi 1.0 screens were rebuilt using the new design methodology and, in January 2006, webAzyxxi 2.0 was formally released as a single application capable of simultaneously supporting multiple hospitals.

Clinician Needs Drive Improvements

webAzyxxi 1.0 was originally designed to be encounter-centric, rather than patient-centric. While this organization and display of data made sense for physicians in an emergency department (ED) setting (for which Azyxxi was originally designed), it also led to the same patient being listed multiple times in a "find" result or in a location list. As webAzyxxi was used more and more by non-ED clinicians, having the multiple listings for the same patient caused confusion. The solution was to: 1) Use the patient medical record number that was unique to each MedStar Azyxxi hospital rather than the encounter number; and, 2) Set the SQL statement attribute to "distinct" in order to return unique values (i.e., not having already been selected) regardless of the number of encounters for that patient.

Therefore, a search for patient John Doe would return all the John Does with unique medical record numbers across all seven MedStar hospitals. While this does not address the issue of a lack of a master patient index across all MedStar hospitals, it does satisfy the clinician demand to reduce the number of repeated patient names displayed for a find-patient search within each hospital.

Another key change in webAzyxxi 2.0 was the creation of a single database comprised of all patient records from all seven MedStar hospitals, approximately 7 million patient encounters. A primary reason for this change was the fact that unlike users of the in-hospital Azyxxi client, a significant number of webAzyxxi users were accessing patients' records from a non-hospital location (e.g., home or private practice). Nearly one in six MedStar clinicians are privileged at multiple MedStar hospitals--17 percent of active medical staff is credentialed at more than one MedStar hospital--and 10.5 percent of MedStar Health patients get services from multiple MedStar facilities. The remote use of webAzyxxi meant that these multi-hospital credentialed clinicians needed an easier way to retrieve data on their patients at the different MedStar hospitals.

To meet this need, the webAzyxxi team developed a mechanism for a multi-hospital, patient-centric search across all seven MedStar hospitals, or any combination of the user's choosing. The new combined webAzyxxi database enabled not only instant switching among hospital data sets, but also a rapid patient "find" function (often under 5 seconds) across multiple hospital patient encounter databases. [Note: This feature has been built, but not yet enabled, pending approval by MedStar clinical and executive leadership.]

Summary

webAzyxxi has become an integral part of medical practice at MedStar Health. As a modern, component, object-based, three-tier Web-application, webAzyxxi 2.0 is capable of rapid expansion through the introduction of both enterprisewide and per hospital functionality. As it is 100 percent client platform agnostic, webAzyxxi is capable of supporting both today's operating systems and tomorrow's healthcare devices with embedded Web browsers.

Other webAzyxxi 2.0 Features

My List: My List is a custom patient list that automatically includes a user's current patients from all MedStar hospitals (i.e., My List is multihospital) for whom the user is listed as an attending, admitting, consulting, referring or primary care MD. Patients are automatically removed from My List within a user-defined time period after discharge. For example, a user can set a post-discharge period of 1, 2, 3, or 4 weeks before the patient's name is removed from My List. This ensures that all testing done within a few days of discharge is seen and evaluated by the clinician.

Patients also can be manually added to My List, allowing a clinician to add a patient that would not be automatically added to his or her current patient list. Another key feature is the ability to add the entire My List of one clinician to another clinician's My List, enabling the user to easily keep track of patients when covering for other physicians. In addition, webAzyxxi's start page is customizable; the user can change the opening My List (the default) to either a hospital inpatient location or a hospital ED patient list.

Integrated Clinical Messaging of Results: webAzyxxi has an integrated clinical messaging system provided via the MedStar Clinician Portal. This feature was created to enable easier collaboration among clinicians regardless of whether they are MedStar affiliated or not. Clinical messaging enables users to send patient reports electronically directly from webAzyxxi to other clinicians and then notify the recipient via secure e-mail. The recipient receives an e-mail notification with instructions on how to pick up the message or reports from a secure online location.

By Jason M. Kreuter, Ph.D. and Peter Basch, M.D.

Jason M. Kreuter, Ph.D. is associate director, e-Health and Peter Basch, M.D. is medical director, e-Health. Contact them at peter.basch@medstar. net and jason.kreuter@ medstar.net.