HOPENET puts center on path for year 2000.
With a $285,000, two-year grant from the National Library of Science behind it, the Duarte, Calif.-based cancer research and treatment center launched a comprehensive strategic plan to develop flexible and innovative technologies, complementing its state-of-the-art medical and research practices.
Aware of problems in the current system - lack of connectivity, need for software improvement and system maintenance exceeding system value - and that state-of-the art technology would greatly improve productivity, City of Hope embarked on an information system initiative called HOPENET 2000 in 1990.
As the name implies, HOPENET 2000, including planning, education, product design, hardware installation and system placement, is expected to be completed by the turn of the century.
FDDI network connects users
The first step of HOPENET 2000 was the installation of a fiber-optic network connecting the many different systems and users across the center's entire campus of 50 buildings occupying 108 acres.
The network consists of a 144 fiber-count FDDI network backbone, connecting nine campus subnets, which are connected to the backbone via Cisco Routers running 10Base-T ethernet. Intelligent wiring hubs distributed on the subnets provide connectivity to desktop workstations.
The high number of fibers on the FDDI backbone and the extensive use of subnetting offer ample capacity for transporting data, images and video using a variety of transport protocols and hardware platforms. Desktop devices on the network, which are connected to the IBM mainframe by PC gateways that function as IBM terminal controllers, consist of PCs, Macintoshes and Unix workstations.
After the installation of the fiber-optic network, City of Hope concentrated on connecting individual clinicians, researchers, investigators, administrators, libraries, laboratories and support staff, which now can share a variety of clinical information - patient histories, encounter data, diagnoses, procedures, consultations and test results. More than 40 Novell fileservers support more than 1,000 users as well as a variety of Unix workstations, database servers and application platforms.
Data repository links
At the heart of City of Hope's entire integrated information system is a patient data repository linking City of Hope databases and information files from many sources, including the patient medical record, clinical trial data management and administration.
Sue Ann Benner, director of nursing and Information Management Systems, said City of Hope's new system - the repository and clinical applications - would have to support day-to-day clinical decision-making, have an open architecture, provide access by clinicians and researchers for research and serve as a foundation for an electronic medical record.
"The system is the key to providing the clinicians with the information they require to make timely decisions regarding patient care, as well as providing a flexible database for applications and clinical research," Benner said.
To fulfill its many requirements, City of Hope selected the Oacis Healthcare Network, including a patient data repository and an interface engine called Gateway++, as well as clinical care applications developed by Oacis Healthcare Systems Inc. in Greenbrae, Calif. The Oacis system uses a Sybase relational database.
"The main objective is to help City of Hope capture information from all its venues of care," said Ken Lann, Oacis account executive. "The new information system should enhance the center's strategy of tracking all of its patients, even those who may not still use the institution, and to best position City of Hope in its efforts to measure outcomes."
The patient data repository relies on a structured query language (SQL)-standard relational database model called the Service Model. The model allows the user to define clinical data and structure it in the repository in the same way that it is defined and structured in the ancillary system where it originated. Data in the model is organized around a particular service, such as a complete blood test, and the results of that service. This provides both patient-specific and cross-patient retrieval of discrete values, such as a hemoglobin count, stored in the database.
The repository captures data from ancillary systems using HL7-standard interfaces, avoiding the need for specific interfaces, into a Unix-based data gateway that verifies data, loads the repository and distributes the data to other ancillary systems. For example, the patient registration system can send admission, discharge and transfer information to other departments' systems, such as radiology, outpatient scheduling and clinical laboratories.
By configuring the gateway, City of Hope can perform consistency and check data content before it passes onto the data repository loading function. The data is then stored in structures that have been specifically configured for use by the electronic medical record, as well as other structures. In this way, clinicians and other users receive data that they can all understand.
As part of its strategy, City of Hope selected systems that operate on scalable platforms, such as Unix, and interface with HL7 application-level messaging.
Physicians and their staffs can retrieve lab results, patient census data and other information for clinical decision-making on desktop PCs in their offices or at treatment sites. The presentation environment uses a Windows application, retrieving data using standard SQL server commands.
Clinical researchers will soon use Windows and a variety of commercial SQL-based commands, as well as replication server technology. It duplicates the database used for clinical care and stores it in a physically separate hardware platform used only for research. This not only eliminates a slow down of the production database, but also provides quick retrieval for better clinical decision-making.
So far, the patient data repository contains clinical lab information, such as blood tests and chemistry panels; microbiology data; physician transcriptions; and patient encounters, including inpatient and outpatient visits with diagnostic and procedural codes. Radiology reports are expected to be online by September; cardiology results, such as EKGs, are next in line for automation.
Living, breathing information
While the repository stores information and is able to pull it from multiple sources, the electronic medical record serves as the lifetime record of each patient.
"The electronic medical record makes patient information available and accessible at all times, no matter where the patient resides in the healthcare system," Benner said. "Its use is not limited to one person. Instead, it can be viewed by many users simultaneously, thus improving care and eliminating delays in treatment.
"The manual patient record may not have been available to a provider because the patient wasn't active, someone else was using it or it had not yet been filed after a transcription was made," she said. "It could sometimes take four to five days for the paper record to resurface after a dictation was completed, routed to the medical record department, signed off by the provider and then put into the chart. Electronically, it's available in one hour."
Store, retrieve and display
One of the key areas the information system targeted is storing data in retrievable formats so that transcription results can be standardized and used by all providers. City of Hope recognized the need to take the data out of its textual form and store it in codified fields.
Dictation is stored at three levels, ranging from a summary level, indicating the type of report - including consults or discharge - service type and date, and summary of the dictation to a standard paragraph format.
For example, the first level presents data in a summary roster, listing all patients that providers need to see. Intersecting with the list is a column of laboratory tests, radiology and transcriptions linked to each patient. Information in bold indicates new information; red sends up a warning sign. Values are not included.
In the second level, all of the specific tests under lab, for instance, are listed along with their results. The final level provides more detail about each test - who took it, who ordered it, when it was done and normal values with which to compare results.
Once the data is stored in the repository in its various formats, Oacis' clinical care applications provide a way to view the information. "In short, we wanted to ensure that the user could understand the data and receive some value from it," Benner said.
The clinical display offers an intuitive way of looking at results by drilling down to the smallest detail, Lann said. The application has the ability to choose a variety of formats to display the data, including point and line, bar and scatter graphs and numerical depictions of values used for trending data. Textual values and dictation are displayed as complete paragraphs of text. With just a touch of a toggle switch, the same data can be viewed numerically or graphically.
City of Hope anticipates adding other applications to its information system during the next year. It currently has a one-way patient appointment scheduling system from EPIC, which displays rosters of outpatients by appointment times. Providers can also view lab results to decide if a patient needs additional tests prior to an appointment. The future holds a two-way interface in real-time.
By December, the center will add a clinical documentation system that will enable nurses and physicians to record patient histories, observation values, vital signs and other measurements about patients that will then enter the electronic medical record. The data can be accessed by anyone instantly.
Thirdly, City of Hope plans to interface its current pharmacy system, which displays drugs and documents drug administration, with the Oacis Healthcare Network. Also in the pharmaceutical field, City of Hope foresees adding an expert dosing system as a workstation enhancement. It can scan the data repository for drug conflicts, contraindications and adverse reactions when a pharmaceutical is ordered, decreasing errors and eliminating conversations between doctors and pharmacists.
By June 1997, the center will implement an order management system that can place orders for services, such as lab tests, medications and nursing functions, and send the orders to related systems.
Finally, the center is considering implementing Oacis census management in addition to its current registration system and Oacis case management, a collection of automated planning tools.
The census system tracks patients throughout the institution, follows their transfers from inpatient to outpatient status and registers them into the system.
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|Title Annotation:||Technology Information; City of Hope National Medical Center|
|Publication:||Health Management Technology|
|Article Type:||Cover Story|
|Date:||Oct 1, 1996|
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