.jpg) Keith J. Dreyer, DO, PhD (left), director of medical imaging, and John Glaser, PhD, vice president and CIO, Partners HealthCare System, Boston. |
Countless times each day, an army of Boston-area physicians and staff go online to view radiology images and reports available from roughly 20,000 workstations, desktop computers, and personal laptops in clinics, emergency departments, intensive care units (ICUs), surgery suites, patient wards, and administrative offices at the eight hospitals and various satellite facilities that form Partners HealthCare System, Inc, Boston. The radiology images, of which there are 75 million, are accessed with heretofore unimaginable convenience thanks to the advanced state of development of Partners HealthCare System’s homegrown, enterprise-wide electronic medical record (EMR) system.
Most of the work on that system took place at Massachusetts General Hospital, Boston, largest of the Partners Healthcare System institutions, where four separate, yet linked, EMR initiatives have been underway since the mid 1990s. One of the initiatives belonged to the department of radiology there. That department had been planning to establish for itself an all-electronic environment, but realized that success would forever elude it unless the envisioned filmless operation was part of an enterprise-wide EMR.
Information On DemandOptimized for WAN deployment, the Epic electronic medical record? is ready to install. Had the luxury of time belonged to Partners HealthCare System, Inc, Boston, the hospital consortium might have chosen to wait a few years before moving ahead with its rollout of an enterprise-wide electronic medical record (EMR). That way, rather than going to the expense and effort of creating a homegrown EMR, Partners HealthCare System would have been able to purchase an EMR from a company strategically allied with AMICAS, Inc, the supplier of Partners HealthCare System’s Web-based EMR to picture archiving and communications system interface and image viewer. That EMR company is Epic Systems Inc. Epic’s EMR, called EpicCare, includes features such as
It also offers robust packages of additional features specific to the inpatient and outpatient environments. THE NEW HEALTH CARE CURRENCY“The EMR is the information currency of the new health care economy,” Khiang Seow, Epic’s director of software development, clinical products, contends. “Whether health care organizations adopt an EMR or have their new patients bring their electronic records in, the EMR will dominate health-record communication. No large provider group will be exempt from adopting one if they hope to stay viable in today’s marketplace. “Furthermore, at the rate that new technology is introduced, there will be more delivery methods available to support EMR technology, thus increasing the market for the EMR.” Seow says that a big driver in the demand for the EMR is the cost saving. “An EMR is vital to staying competitive in today’s market,” he says. “Clients have dramatic return on investment benefits. These include up to a 15% increase in overall revenues, improved utilization, up to 100% recapture of chart-storage floor space, improved productivity, reduced costs of testing, up to a 95% reduction in transcription expenses, up to a 100% reduction in the cost of paper-chart handling and paper-chart supplies, decreases in the cost of malpractice premiums and per-member, per-month enrollment fees.” Like the EMR developed in-house by Partners HealthCare System, Epic’s product operates in a thin-client configuration. “We use Windows? Terminal Server? with Citrix MetaFrame,” Seow says. EpicCare can also be run in a more traditional client-server configuration, and on any of several major-name server platforms using either Windows NT or 2000 workstations, he adds. HIGH SCALABILITYEpicCare communicates across the local-area network and wide-area network (WAN) infrastructure, and is optimized for WAN deployment, Seow says. “A client-server configuration typically requires bandwidth of 5K per second per user.” As he explains, it uses Transmission Control Protocol/Internet Protocol for client-server communications (TCP/IP), and Health Level 7 and American National Standards Institute (ANSI) standards for communicating with external systems. It supports multiple network topologies, including Ethernet, Asynchronous Transfer Mode, Fiber Distributed Data Interface, and Token Ring. Seow indicates that EpicCare uses object-oriented tools and languages, including the Component Object Model (Microsoft)/Digital Imaging and Communications in Medicine model. Its database is Open Data Base Connectivity and Standard Query Language compliant. “EpicCare is highly scalable, being able to support thousands of concurrent users and millions of patient records,” Seow says. “One of our market differentiators is EpicCare’s use of a universal patient record: a single record accessible from any care setting. Updates to patient information documented anywhere in a multisite enterprise are immediately available to all authorized users.” EpicCare makes information available where providers need it, Seow says. “Users can access EpicCare from workstations, thin-client devices, and wireless laptops,” he says. “The EpicCare record is also accessible to an organization’s clinicians via secure Web connection, so key clinical information is available wherever and whenever providers need it. Organizations have the ability to extend Web-based access to affiliated providers and even to patients, giving them an unparalleled strategic advantage in reaching out to the community and becoming the provider of choice.” Seow takes the position that decision making in today’s health care environments requires the kind of instant access to information made possible by EMRs. This, he believes, is especially true where diagnostic images are concerned. “Traditional radiology reporting represents one specialist’s interpretation of the image,” he says. “Other specialists such as orthopedists or thoracic specialists may have differing views as a result of different training, and may be looking for additional information not normally reported. For example, the orthopedist may want to see the exact nature and alignment of fracture fragments, evaluate callus formation in a healing fracture, or visualize the alignment and seating of a joint prosthesis. In any event, specialists need to have ready access to these images to perform their own interpretations.” Seow suggests that EpicCare has garnered strong acceptance among physicians and other clinicians who regularly use it at the point of care. “Because it provides excellent response times, typically measured in subseconds, EpicCare is a practical solution that clinicians have found extremely helpful in their daily work,” he says. “The system has no mandatory work flows, so clinicians can work the way they want. Epic’s proactive decision support provides point-of-care alerts and reminders relevant to each patient’s condition. These alerts can contain links to order sets and interactive protocols, making it simple for clinicians to comply with an organization’s best-practices guidelines.” Seow says that Epic and AMICAS decided to become strategic partners in the EMR arena because both companies share “some of the same philosophy on product development, such as a commitment to develop what the customer needs, a quality product that is easy to use and install, responsiveness to questions, great customer support, and conforming to and using standards.” -Rich Smith |
Keith J. Dreyer, DO, PhD, is Partners HealthCare System’s director for medical imaging and Massachusetts General Hospital’s vice chair of radiology, informatics division. He says, “This hospital alone is such a huge institution that we would never have been able to deploy an enterprise-wide image distribution system ourselves, as a department. We needed the umbrella of the EMR in order to achieve our departmental goal of drastically reducing the need for film outside the department.”
MAKING IMPROVEMENTS
Founded in 1811, Massachusetts General Hospital is the third oldest general hospital in the United States and the oldest and largest in New England. The 853-bed medical center offers sophisticated diagnostic and therapeutic care in virtually every specialty and subspecialty of medicine and surgery. In a year’s time, its main campus and satellites together handle nearly 80,000 emergency-department visits, 30,000 surgeries, 2,100 births, and over a million outpatient encounters and 500,000+ diagnostic imaging procedures.
In 1994, Massachusetts General Hospital joined forces with another famed Boston institution, Brigham and Women’s Hospital, to create Partners HealthCare System. The system now includes six other hospitals and their satellites, plus a rehabilitation center, a psychiatric care facility, several home health agencies, and a network of primary care physicians. Within the context of this dynamic and growing delivery system, the need arose for the rapid and reliable exchange of patient data. This was a need that could not be met because each hospital had its own electronic information system, and most of them were incompatible. The solution called for development of an enterprise-wide EMR, but making data access easier was not the only reason that Partners HealthCare System wanted to pursue this goal.
John Glaser, PhD, Partners HealthCare System vice president and CIO, says, “We saw the EMR as an answer to problems affecting various ambulatory care processes. For example, for every 100 ambulatory care patients in our system, 5.5 were seeking attention because of an adverse drug event related to a prescribed medication, and 28% of those were serious or life-threatening cases.”
Glaser continues, “We also were having problems providing follow-up care. Consider marginally abnormal mammograms. The proper procedure is to have follow-up contact with the patient after 6 months and repeat the examination. In 36% of cases, there was no evidence at all of either a follow-up contact or a repeat examination occurring. Then, there were referrals. In one of four instances, the specialist did not receive complete information and thus did not know why the patient came to see him or her. One time out of five, the referring physician had to repeat the referral because the question that he or she had hoped that the specialist would answer was not addressed due to the incompleteness of information supplied to the specialist.”
Glaser says that these numbers were uniformly unacceptable and out of sync with Partners HealthCare System’s efforts to provide high-quality care. “It was not possible to measure quality, let alone provide it over a continuum, with gaping holes in our ability to gather and assimilate data,” he says. “The gaping holes existed, in large part, because of our reliance on paper records, especially in outpatient care.”
MAKING the RIGHT DECISIONS
The four initiatives that gave rise to the Partners HealthCare System EMR, as it now exists, sought, individually, to tackle the objective from the perspectives of specific types of users. One took it from the viewpoint of researchers, another from that of on-campus clinicians, and a third from off-campus physicians and staff. The fourth addressed the needs of consumers of radiology images (accordingly, only this initiative was owned by the radiology department). “It was decided that pursuing EMR from four different directions, but with an eye toward one day pulling them all together as a unified product, would be the most cost-effective and rapid way to proceed,” Dreyer says.
The initiatives got underway within a year of the formation of Partners HealthCare System. By 1996, the first attempts at unifying the projects commenced, involving an effort to establish both a master patient index and a clinical data repository. “This spared us the need to standardize our hospital information systems (HIS),” Dreyer says. “We felt that it would be less expensive and disruptive to the hospitals if they all kept their individual HIS and we, instead, developed a master patient index that would arbitrate among all of the different record systems available at those hospitals.”
The master patient index was completed about a year later. With it, the hospitals gained the ability to load patient records, including laboratory values and radiology reports, into a readily accessible common data repository. This, however, required the development of an integrated accession-numbering scheme to guarantee that data on a particular patient culled from various areas of the enterprise pertained to that patient only and not to someone else with a similar name, Glaser notes.
Knowing that images would eventually be included among the accessible, common-repository data, Partners HealthCare System decided to employ the Internet as a transmission mechanism. The type of protocol to use was a thorny question, Dreyer recalls. “That was not an easy choice to make because, back in 1996, the Internet browser and server wars were raging, and there was vigorous debate over whether the Internet would be truly platform independent. Those contests made it difficult to know the right course to steer. Eventually, what the outcome was going to be became clear. We elected to go exclusively with Microsoft’s desktop and Internet applications. In retrospect, we made the right decision.”
Another correct decision was that which resulted in use of technology developed by AMICAS, Inc, Newton, Mass, to connect the radiology department’s picture archiving and communications system to the EMR. “The AMICAS system, AMICAS Enterprise OfficeSM, is a standards-based, flexible, and scalable platform for medical image management over both the intranet and the Internet,” Dreyer says. “When we first started working with AMICAS on this project, there was no other vendor we knew of that could offer us this kind of connectivity to an EMR. Still, to this day, AMICAS has one of the most efficient EMR connections out there. It’s a very-thin-client approach, ideal for this kind of application.”
EMR has been an enterprise-wide reality for Partners HealthCare System since 1998. In one of the first iterations of the system, users logged on and were greeted by an on-screen dashboard. “We called it the clinical applications suite,” Dreyer says. “It was a thick-client product that allowed different applications to become active as the user needed them. For example, if a user looking at a particular patient clicked on ‘radiology,’ he or she was shown all of the available reports for that patient. An icon appearing next to the title of each report alerted the user as to whether an accompanying image was also available. If the user then clicked that icon, it caused the system’s image-viewing software to be launched. The user would then be able to page through all the images from that particular examination.”
The current version of the EMR also lists available reports and denotes image availability with a clickable icon. The difference, however, is that instead of starting a software application loaded on the user’s workstation or computer, clicking the icon launches a Web page. “When the user clicks the icon, it sends to AMICAS, via secure connections, an Extensible Markup Language (XML) Web call containing the accession number of that requested examination,” Dreyer says. “The result is that the user has a seamless connection to the data and easy, reliable, fast navigation through the displayed images.”
Establishing an interface with AMICAS and the Internet proved straightforward. “It took us about a week to set up everything,” Dreyer says. “We encountered surprisingly few problems.” One reason for that was the absence of any need to install a data network. That had been done years earlier. “Our network, already in place, was such that it had more than sufficient bandwidth to support the data volume that would traverse it once images were added to the EMR,” Dreyer says. “This network had been set up independent of any needs that radiology had. The information-services department simply did an outstanding job of anticipating the amount of traffic that would eventually be crossing the network. As a result, when we began pushing these images out over the lines, there really were no bottlenecks. In effect, the roads were already paved for us when we were ready to start using them.”
Early in the implementation process, the information-services team installed a 10MB shared Ethernet network throughout the enterprise. Later, it upgraded this to a mix of 100MB shared and 10MB switched Ethernet. “The opportunity presented itself to convert to a different network technology,” Dreyer recalls, “but we elected not to do so. That turned out to be a good decision. Any gains to be attained from those technologies would have come at a great price in terms of equipment outlays and installation costs. Switched Ethernet has been advantageous for us. The routers are intelligent enough to be able to control traffic in such a way that, if two users need to talk over a line, they are not broadcasting to everyone out there, but just to each other. If you have a very busy modality that wants to push information over to a Web server, or a Web server that wants to push data over to a client, they can connect in a virtual, direct way over the network without tying up everyone else.”
CHANGING RELATIONSHIPS
Every image generated in a study is made available to users of the EMR, according to Dreyer. “We can do this because, for one, the images are sent in compressed form, at a ratio of about 10:1,” he says. “This makes transmission across the network more efficient.” It also allows storage media to hold 10 times as much image data. Dreyer says, “The AMICAS technology is such that it can readily store tens of millions of images and make any one of those available in seconds. What we would love to do instead of making all images from a study available, however, is offer sampled images; that is, include only the two or three most relevant images with each report. We attempted this about 3 years ago, but ceased when we observed that it was proving too time-consuming for the radiologists who had to select the samples.”
Dreyer would also love to offer users the ability to click open an image detail of a key finding mentioned in the radiology report. “The key finding would be hyperlinked to the appropriate image or images,” he explains. “From an image-distribution standpoint, we can make this happen, but that is not the challenge. How do we best accomplish this at the interpreting radiologist’s workstation with regard to work-flow processes? Fortunately, all of our reports at Massachusetts General Hospital are created by voice recognition. We are working with software vendors now on endowing the system with the capability of allowing the radiologist, as he or she dictates text, to select an image area and say into the microphone, ‘Click on this image,’ and it will automatically create the necessary hyperlink.”
Dreyer points out that there are no EMR screens available to radiologists only. “Our radiologists use the EMR the same way that other clinicians do in other departments,” he says. “We use it to access laboratory data, chemistry, and demographics, either before or after a radiological examination, in order to gain more information on the patient. This is helpful in our ongoing efforts to improve the quality of patient care.”
Dreyer indicates that the EMR has affected radiologists’ practice patterns in other ways, as well. “EMR has changed how we communicate with ordering physicians,” he says. “Before, when we conducted rounds in the ICUs for the education of our rotating trainees and fellows, we would have opportunities to interact directly with our ordering physicians. Now, with the convenience of EMR, that technology has become the conduit of information dissemination between radiologists and clinicians. Consequently, the face-to-face interaction has declined dramatically. Of course, ordering physicians still do come down to the radiology department to ask questions, but even that happen a lot less frequently now.”
SECURITY CONCERNS
Dreyer estimates that the number of clinicians with access via EMR to reports, images, and other records stands at around 6,000. These are joined by more than 14,000 administrators and clerical employees who are able to look at patient data as well, and the number of users is growing. Naturally, there has been concern, from the beginning, about ensuring the security of the EMR-available information. “Security involving the technology was reasonably easy to address,” Glaser says. “We have Internet encryption, we have set in place good audit trails, and we have made sure that the authentication mechanisms are first rate. In addition, we have instituted virus protection, firewalls, and reasonable disaster-recovery protections.”
Glaser continues, “The other part of security is confidentiality. Here, we are talking about the human dimension. To address that, we have developed a process that revolves around things like making sure that our employees are educated about confidentiality protection, that we have and adhere to policies and procedures for releasing information and obtaining informed consent from patients, and that entities to which we link our systems understand our confidentiality practices (and that we understand theirs).”
The contributions, including security, of the information-services department were instrumental in the success of the EMR effort. From the beginning, the department assisted in formulating the overall plan for integrating a variety of clinical data at the end user’s desktop. “We made sure that the technologies and standards supported the needs of radiology so that it would not be necessary to run separate networks,” Glaser says. The information-services department also supported the radiology department by helping to train thousands of end users to operate the EMR and access data. “We also spent time talking to hospital CEOs, CFOs, and members of the board of directors, helping them to understand the project priorities, what funds were needed to support those projects, and why budgets might have to grow,” Glaser says.
Although the EMR is in place and fully operational, the work is far from completed, according to Dreyer. “Our next steps will be to follow the technological curve,” he says. “For instance, we might explore wireless access to the Internet by giving clinicians wireless tablets they can carry with them as they make their hospital rounds. We will also be addressing issues such as extending our intranet firewall protection securely out to the Internet. Above all,” he continues, “the goal will be to have the thinnest clients possible, making sure there is the least possible amount of computing occurring on the appliances themselves, be they wireless tablets or desktop computers, so that we can maximize our ability to keep our software consistent with where the Internet is going, taking advantage of where browser technology is headed.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.
