One PACS was selected for all hospitals in the PeaceHealth system. John L. Haughom, MD, and radiologist Cathryn Chicola, MD, call up images from the system-wide PACS, which spans six hospitals and many auxiliaries in three states.

Clinicians on staff at any of the six hospitals or numerous auxiliaries operated by PeaceHealth in the Pacific Northwest can electronically access patient charts, including images. No big deal these days, except for the fact that so can clinicians who are not on staff or who otherwise lack hospital privileges. And so can patients themselves.

What PeaceHealth has done is taken the concept of the electronic medical record, injected it with massive doses of growth hormone, and then made it conveniently accessible by all comers with a legally valid need for patient information, thus creating an encompassing system the organization calls a community health record – CHR, for short. PeaceHealth has spent millions on this endeavor over the past decade, but is reaping impressive dividends as the clamor for access spreads throughout the community.

“We intend the CHR as a tool available to any practitioner, regardless of whether they have a relationship with us; in fact, we’ve made a decision to make it available even to our competitor health systems in the markets we serve,” says internist/gastroenterologist John L. Haughom, MD, senior vice president of the Division of Healthcare Improvement for Bellevue, Wash-based PeaceHealth, with facilities throughout that state and Oregon and Alaska. “At present, we have about 16,000 password-assigned users of our CHR, about 6,000 of those being independent physicians and other care providers who are not employees of the PeaceHealth organization.”

Independent clinicians access PeaceHealth’s CHR for a market-based fee and by means of an ASP delivery model over the Internet. Once they log on (and depending on the level of access they have purchased), those external customers can utilize the CHR or its individual component systems, which include enterprise PACS-RIS.

“The imaging component has by far been the most successful of any in the CHR, an enormous crowd-pleaser, if you will,” says Haughom from his office at division headquarters in Eugene, Ore, where the CHR machinery resides.


PeaceHealth’s community health record – intended to improve safety and quality of care marketwide – is unquestionably an initiative of sweeping magnitude. Contained already in its 2.5-terabyte SQL database are records on 1.4 million patients, and that number is expected to burgeon over the next several years as the CHR’s capabilities are enhanced.

“On the inpatient side, essentially everything is online now and available through the CHR, with only two exceptions: physician’s daily written progress notes and physician orders,” says Haughom, who indicates that projects currently are under way to address both deficiencies. “We should have physician order entry up within the next 18 months.”

Although CHR-using physicians cannot yet write electronic orders for services such as imaging studies, they can for outpatient medication prescriptions, and this year, through the CHR, they will type in an estimated 2 million pharmacy orders, says Haughom. Meanwhile, the CHR also is being used to support clinical-improvement programs, including chronic-disease registries and disease-management programs.

Patients too can use the CHR to gain access to their own charts.

“We have a web-based tool that allows patients to go online to update their demographic information, request appointments, request prescription renewals, and send encrypted e-mails to their providers,” Haughom says. “Additionally, they can review their lab results, their doctors’ reports of findings, vaccination histories, and the like.”

Donn McMillan, vice president of information technology and chief information officer for PeaceHealth, finds the infrastructure required to make all this possible nothing if not remarkable.

“To me, the most amazing thing about the network is the distances involved and the difficult topography it travels,” he says. “To go from Eugene in Oregon to Ketchikan in Alaska means crossing mountains and going undersea – yet the response time in Ketchikan is the very same as it is in Eugene, whether you’re talking about retrieving text or images.”


Not-for-profit PeaceHealth last year reported gross operating revenue of about $1.3 billion. Four percent of that sum was allocated to pay for the CHR initiative during that same time, Haughom reports.

“The expense is worthwhile because, while CHR is a technology, it also qualifies as a business strategy,” he explains.

The origin of PeaceHealth’s CHR initiative dates back to 1991 when an in-house task force convened to explore solutions for predicted coming changes in health care delivery.

“We became convinced that care would be significantly different after 2000,” says Haughom. “After studying the trends already starting to take shape, we determined that economic forces and technologic advances would combine in ways necessitating that we provide care in as integrated and seamless a fashion as possible.”

The following year, Haughom – a taskforce participant – was invited to spearhead development of an action plan. Contented to be in clinical practice, Haughom politely declined the offer. Nonetheless, he agreed to serve as an informal advisor to the CEO on various aspects of that effort. In 1993, Haughom took on a more substantive role by devoting half his work week to it. Not long afterward, he decided to set aside his clinical activities in order to concentrate on the project full-time.

“In 1994, our focus was on creating a vision for what the IT infrastructure needed to look like if we were going to support this new form of care delivery,” he says. “We decided we needed an IT infrastructure that would seamlessly provide all the information a clinician might require, no matter where he or she was delivering care – be it in the hospital, in an office, or at any other site, up to and including the patient’s own home – and that it would be coupled with advanced decision support to optimize their delivery of that care.”

The initial implementation of this desired IT infrastructure got under way in early 1996, with the wiring of each of the PeaceHealth hospitals.

In 1999, the CHR itself began rolling out. However, it was not until 2002 that architects of the initiative felt the time was right to develop the imaging component.

“With our focus until then on infrastructure, we couldn’t devote the resources necessary to also tackle images,” Haughom says. “We’d been holding off on that for another reason, too – we didn’t feel the technology to efficaciously manage and distribute images and allow for full integration with the CHR was sufficiently advanced prior to that point.”

The imaging implementation commenced in May 2003. It was conducted in three phases, beginning with installation of an enterprise RIS.

“We added PACS second, and the final piece was cardiac imaging,” Haughom says.


Because the PeaceHealth CHR is such a far-reaching system, the hardware and software undergirding it are exceptionally powerful, not to mention reliable, flexible, scalable, and fast. The same is true of the hardware and software forming the basis of the RIS and PACS components, as well as those of the electronic medical record and other major pieces making up the CHR, such as a practice-management module. All of these systems and subsystems come from a single vendor.

“We did not take a best-of-breed approach,” says Haughom. “By insisting right from the start on standardization, we were able to very easily integrate the CHR’s building blocks. Integration would have been a mess had we a hodgepodge of systems instead. Avoiding that mess saved us significant sums.”

McMillan says that while this strategy of eschewing best-of-breed eliminated programming headaches and extra expense, the trade-off was the organization had to make do with a few not quite ready-for-prime-time systems.

“Our patient-accounting package is a good example,” he says. “It’s a fine product, but it wasn’t everything we expected.”

The CHR’s core machinery is based at the PeaceHealth data center in Eugene. The hardware consists of a pair of mainframe servers outfitted with the most powerful processors available for this application. These servers operate in tandem at all times, and each contains a database that is the mirror of the other’s so that, if one goes down, the system will continue functioning without users noticing.

“One thing about a CHR – users quickly become very dependent on it,” says Haughom. “Therefore, you have to do everything humanly possible to ensure that your CHR never goes down.”

The decision to situate the CHR hardware and software in a single location was a good one as far as McMillan is concerned, but he says it also introduced an odd challenge that to this day defies facile solution.

Adding the Imaging Component

As with every other key element of the PeaceHealth community health record (CHR) initiative, image distribution is conducted via a single implementation. Accordingly, when the organization went searching for an enterprise PACS to serve in that capacity, it wanted technology that would offer ease of integration and unsurpassed performance capabilities, be dramatically expandable and upgradeable, and bear the brand of a maker with a stellar reputation.

“We formed a PACS selection committee to identify the right equipment,” says John L. Haughom, MD, senior vice president of the Division of Healthcare Improvement. “This committee, which I chaired, consisted of a variety of stakeholders, including physician users, radiologists, IT specialists, and administrators. The objective was to find a PACS that would grow with us and be able to accommodate the increasingly complex images we knew our facilities would be generating. It had to allow us to be as efficient as possible so we could manage those images well and ensure rapid distribution to users. It had to allow our imaging departments to attain higher levels of productivity.”

The CHR data warehouse is massive enough to accommodate PACS images from the imaging departments and centers in PeaceHealth’s three-state market. However, to prevent it from being overwhelmed, the organization has decided not to convert historical film images to a digital format unless necessity dictates.

“If a patient comes in, gets a CT scan, and we find out they had a previous study that we want to compare it to and that older study is on film, we’ll waive our policy and digitize it in order to add it to the imaging database,” he explains.

Meanwhile, the process that a doctor in the community follows now to order and then receive imaging studies on his patients is no different today than it was before the CHR debuted.

“As in the past, referring physicians send patients to a PeaceHealth facility where imaging services are offered,” says Haughom. “The patient is registered and managed via our enterprise RIS, which then shares the information with the CHR. As soon as the modality technologist completes any final adjustments to the images he’s taken, those images are immediately available to the referring physician via the CHR or through the web-accessible PACS.

“No matter which route they go, they can get a look at the images incredibly fast. Their cycle time for evaluating their patients has been dramatically reduced as a result. No more waiting a day or a week or two to get those images, as was the case in the days of film and no CHR.

“Another advantage of this speed of image availability is that it’s become vastly easier for referring doctors to collaborate with radiologists. So, for us, the PACS-equipped CHR is resulting in more interaction between radiologists and referring doctors, which we think is a very positive development.”

–R. Smith

“Our hospitals span two time zones, with the CHR based in one and our sites in Alaska in the second,” he says. “Left unaddressed, we’d have had a situation where all our records from the Alaska time zone would be incorrectly dated, continually. The economic, legal and clinical ramifications of that would be staggering.

“Almost every single vendor we’ve contracted with has had to change their software in order to support this multi-zone situation. You wouldn’t imagine it, but it’s actually a huge programmatic change to make. Some have even chosen to just walk away because it’s too daunting. In other instances, we have a few systems that we’ve had to create workarounds for because there’s no other way to deal with the problem.”


Having one data center and one set of software supporting all facilities across the three states required a supremely robust wide-area network in order to achieve satisfactory response time.

“A CHR will fail to gain user acceptance if system response time is longer than a second,” says McMillan. “So you cannot cut corners when it comes to building the supporting infrastructure.”

With PeaceHealth’s CHR, the amount of time that lapses once a user hits “enter” or clicks “OK” when requesting an image until it pops up on screen is 0.5 seconds, McMillan indicates.

“Ours is a high-performance network,” he says. “On each PeaceHealth campus, the network is fiber optic, largely 1-gigabyte Ethernet. The backbone running between facilities is also fiber-optic, very high-speed, and it’s leased from major carriers. Our funding covered the costs of extending the network right up to the faceplate of the independent physicians’ offices, so all they had to do in order to achieve connectivity with our CHR was plug in.”

Independent physicians out in the community can connect to the network with their choice of a PC, laptop, PDA, or workstation, provided it meets PeaceHealth-specified minimum system requirements.

“Basically, if you’ve bought any Windows-based computer in the last year or two, you’ve almost certainly got a computer that meets the system requirements,” says satisfied user Christine F. Kollmorgen, MD, FRACS, a Eugene general surgeon in independent group practice. “When my nine-doctor office signed up for CHR access last year, we had only dinosaur computers, so we had to buy new ones to be able to access the system.”

Kollmorgen utilizes the CHR routinely to view images. Many of those are pulled up on a PC, but more often she retrieves them at a workstation.

“The workstation is where we display larger images, images where we need to see finer detail, and images that are dynamic, such as some of the angiograms,” she says. “And each of our 11 exam rooms has an LCD monitor.”

All of Kollmorgen’s patients are entered into the CHR. To prevent record-keeping confusion, she uses in her office the same identifier number PeaceHealth has assigned each of them.

Kollmorgen says there is much to like about the CHR. “I can access information about any visit my patient has had with any other provider tied into this system,” she enthuses. “I can obtain medication lists. I can even order prescriptions electronically without fear of inadvertently duplicating medications that might already have been prescribed for the patient by another provider in the system.”


Independents like Kollmorgen access the CHR under terms of a lease agreement. The fee they pay is very reasonable – and fully legal (Haughom says a bevy of corporate lawyers pored over the proposed rates and terms to make sure there would be no violation of Stark rules or other arcane regulations that might land PeaceHealth in hot water). Fees vary depending on which package of services users select: choices range from an entry-level offering to a full-spectrum version and a couple of mid-range options in between.

Haughom will not disclose how much the organization takes in from the leases, but allows that the revenues they generate are sufficient to cover PeaceHealth’s costs.

Training is necessary for first-time users but also for seasoned users any time PeaceHealth rolls out new CHR functions.

“We initially thought we’d provide training to the doctors and nurses in multiple 2- or 3-hour sessions,” says Haughom. “We quickly learned they had neither the time nor patience for that format.”

Training now is delivered in a single session lasting less than an hour, and users can go online for interactive tutorials to refresh their memory about how to perform various tasks or to learn for the first time about procedures not covered in the training session. Each PeaceHealth region has a CHR instructional unit staffed by 15 to 20 trainers whose work is supplemented by departmental-level teams of “super-users” (highly trained peers capable of providing at-the-elbow support to their colleagues).

Haughom cannot say how much money it costs to provide training.


PeaceHealth’s CHR has come a long way since its first iteration; however, McMillan says the journey is far from ended.

“Users cannot currently access lab-generated images,” he says, assuring this will be remedied in relatively short order. “Also in the works is a component to capture complex graphical information of the sort routinely generated in ICUs and CCUs. And, during our next fiscal year, an initiative will be undertaken to permit digital scanning of reports and other clinical information produced on paper in the offices of outside users.”

Other enhancements still to come include capture of home health information and two-way integration with stand-alone electronic medical records systems owned by independent physicians in the community.

However, even after all these capabilities are added, it still will not bring the story of PeaceHealth’s CHR to a close.

“I think our CHR, like smaller EMRs, will go through an evolution,” says Haughom. “The stage we’re in now is passive EMR, where we’re aggregating all the information about patientstheir labs, images, written reports. Coming will be active EMR where the system offers real-time decision support in the form of expert rules – to remind users of things like drug conflicts, dosage information, and allergies – and retrospective decisions.”

Beyond that will be the personal EMR. Haughom describes it as a system containing vast databases of individual patient genome information.

“Genetic profiles of patients in an EMR will allow us to precisely tailor treatments to the individual patient,” he says.

Meanwhile, in the here and now, PeaceHealth wants to demonstrate the success of what it has in place already.

“We’ve compiled a number of reports looking at improvements in safety and quality of care,” Haughom says. “I can’t share specifics, but the indicators are up in every metric we’ve examined. Thanks to our CHR initiative, we’re achieving our goals of improving clinical care, of being able to make decisions better, of improving outcomes throughout the communities we serve.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.