When the radiologists at Saint Alphonsus Regional Medical Center (SARMC) in Boise began planning for Idaho’s first filmless outpatient imaging center, Intermountain Medical Imaging (IMI), a large part of their vision was the creation of state-of-the-art access to medical information for other health care providers. Jeffrey Seabourn, MD, staff radiologist, called on the information technology department at SARMC to assist in this task.

“Opening our new outpatient imaging center as a filmless facility was a no-brainer,” Seabourn says. “The real challenge was not in establishing an enterprise-wide solution for distribution of digital imaging studies, but taking it a step further with integration into an electronic medical record (EMR).”

For months the SARMC information technology (IT) and radiology department staff met weekly to design an innovative new system that not only allows physicians and other providers online access to radiology images but, with a single access point, visually integrates that data with multiple other information systems used for patient information.

“The Saint Alphonsus Department of Medical Imaging has spent a considerable amount of time over the past year or so looking at our future and how we can work with our radiologists to improve services to them and our other customers,” says Terry Krogstad, director of medical imaging. “PACS (picture archiving and communications system) and the integration of radiology data with other clinical data were identified as crucial to making effective changes in our processes.”

The First Step

The first step in this journey was the purchase of a PACS for the IMI outpatient facility. (The same system was subsequently purchased for the hospital.) The radiologists at SARMC, key to this integration plan, understand that their work product is not only excellence in diagnostic services, but also how the product as a whole is delivered to the referring physician community as part of a patient’s overall care. The vision and leadership of the group enabled us to work together for a common solution for integration of digital imaging data from both IMI and the SARMC Department of Medical Imaging into the EMR.

Over the past 4 years, Saint Alphonsus had begun attempts to integrate information through the development of two tools: an interface engine and a data repository. Using HL-7 as the common standard, the interface engine and the repository were built. There are currently 46 systems integrated via this approach.

To best distribute the information from the repository, a new front-end interface was developed for use over the World Wide Web. Saint Alphonsus developed a Web-based EMR called Clinician Desktop Web or CDWeb. This EMR uses Netscape Navigator as a common interface for information.

When the information technology department started working with the radiologists, it was inspired to try to do more than had been done in the past to integrate and distribute information. IT department leadership had been aware of a new standard being developed and decided this was the time to implement it.

A New Standard

This new standard, HL-7 Clinical Context Object Workgroup, or CCOW (pronounced sea-cow), is a dramatic new breakthrough in using information. It allows clinical information to be visually integrated through the development and use of a software component called a context manager. The context manager works in the background to coordinate all clinical applications-such as patient charts, digital radiology images, and laboratory or pharmacy results-around a single patient name, or context. This then allows front-end viewing with CDWeb of information in its native form with total functionality. CCOW enables a dynamic and interactive use of data, not merely a static view.

Saint Alphonsus is among the first hospitals in the nation to implement this technology, recently completing CCOW-enabling of CDWeb and the PACS network. The CCOW-enabled products will go live this summer. This project undoubtedly was instrumental in helping SARMC to earn recognition by the American Hospital Association in the Hospitals & Health Networks magazine as one of the top 100 wired hospitals in the nation.

Beyond the obvious advantages for clinical information, the use of this standard allowed applications to be linked in days at an estimated savings of about $200,000 per application because of the plug-and-play convenience of the context manager.

Visual integration allows physicians or other providers to view and easily coordinate multiple applications with their workstations. This capability means physicians can navigate easily among several radically different clinical applications with only a mouse click or two. The viewer does not have to be concerned with switching between interfaces, multiple log-ins and passwords, or repeated entry and exit from different specialized systems or databases, each of which may take time to load and search.

In the past, if family practice physicians wanted to look at the results of a patient’s MRI image, they were restricted to a static view or report either on hard copy or drawn from the clinical data repository, but still basically quantitative or static.

With the implementation of CCOW as a part of the PACS system, those same physicians can enter the patient information and have all of the native functionality of the PACS system to rotate, measure, or manipulate that MRI image, all from their desktop. If a physician then decides that additional laboratory or other clinical information on the same patient is required, the context manager software will use a patient link capability to allow immediate access to any other CCOW-enabled applications and recognize and locate information on the same patient, with no additional log-in. The physician can switch intuitively, smoothly, and continuously between applications that provide a visually integrated view of that patient’s care. An additional capability of this technology coordinates applications around specific patient care encounters.

“A stand-alone PACS network without integration of patient information through the EMR has obvious limitations,” Lisa Scales, MD, staff radiologist, notes. “The whole idea of integrating our radiology data with other medical information takes us to a new level of service. When a physician can sit at a desk in the office or even at home and not only see information

but also analyze and manipulate it,

that’s exciting.”

Clinicians will be unaware of the operation of the context manager. It works in the background and allows physicians access to familiar applications.

Advantages of CCOW

Advantages to the organization using CCOW technology are that it can selectively choose from among the many clinical applications. It is not necessary to accept only the single-vendor option or upgrade all of its legacy systems to conform. Vendors must modify applications to incorporate the CCOW standard but once done, a context manager is incorporated into the system to achieve plug-and-play.

By implementing the CCOW standard, software vendors avoid the necessity of having to rewrite applications to meet the consumer demands of integrating products. No longer can the silo mentality of viewing software products solely as single departmental applications be sustained. With the move to client/server environments in health care (and elsewhere), vendors can be successful only by integrating and this can be done with the new CCOW standard. The potential of CCOW is that it will enable chief information officers to lead integration efforts and not follow vendor proprietary mandates.

One of the most exciting aspects of this new technology, however, is the fact that it is economically a win-win solution across the board. Not only does it improve the quality of clinician access to medical information, it provides significant savings to the organizations that choose to implement it. Saint Alphonsus will save an estimated $200,000 in hardware, man-hours, and software for each CCOW-compliant application enabled. No longer will time and money need to be spent on conversion of systems. For each application, these estimates are based on: an estimated three man-months of external programming, at 168 hours x 3 x $250/hour=$126,000; plus $40,000 per result interface from the vendor; plus $5,000 in hardware; resulting in $211,000 in savings.

The real bottom line, however, is in improved patient care. That was the original vision of the Departments of Medical Imaging and Information Technology at SARMC at the outset of the integration project. It continues to be their vision for the future.

Leslie Kelly Hall is vice president and chief information officer, and Jan House is a former vice president, Saint Alphonsus Regional Medical Center, Boise, Idaho.