Scott P. Narus, PhD (left) and Paul D. Clayton, PhD

Intermountain Health Care (IHC) is an integrated health care delivery network headquartered in Salt Lake City. Originally formed in 1975 as a not-for-profit organization when the Church of Jesus Christ of Latter-Day Saints donated its 15 hospitals to the community, IHC has grown to include 22 hospitals and over 150 clinics and physicians’ offices in Utah and Idaho. IHC employs more than 400 physicians and has relationships with over 2,000 affiliated physicians. Its hospitals admit 114,000 inpatients per year, and 3.16 million ambulatory visits per year are recorded at IHC clinics. Approximately 773,000 radiology examinations are performed per year. In addition, IHC’s health plans division covers 480,000 patients.

Even before the formation of IHC, research on clinical information systems (CIS) was being conducted at LDS Hospital, Salt Lake City. Pioneering work by Homer Warner, MD,1-3 in the mid 1950s used computers for decision support in cardiology and set the stage for the growth of a new field of academic study: medical informatics. Through the work of Warner and his colleagues at LDS Hospital, one of the first hospital information systems was created. That system, known as HELP,4 is still in use today at IHC’s hospitals. HELP has formed the backbone for much of the CIS research at IHC, and has been instrumental in many of the organization’s quality-improvement initiatives. During an average month, more than 12,000 unique individuals use the HELP system to enter or review patient data.

Today, HELP is used as an example for building the next generation of information systems at IHC. With its expansion into the ambulatory patient setting, IHC found a need for an enhanced system that could span the information needs of clinicians wherever a patient might appear in the geographically dispersed health network. In 1992, commitments were made to begin developing a centralized longitudinal patient record and to make that record available to clinicians at the point of care. The centralized patient database, known as the central data repository, combines information entered by clinicians with data collected from other sources (including HELP) using standard interfaces such as Health Level 7 (HL7). In this environment, clinicians can enter and view laboratory, medication, and allergy information; maintain a common patient problem list; document history and physical examination findings; complete progress notes; communicate with other clinicians about patients; and generate reports. Regardless of the system used, the goal of IHC has always been to use information systems to influence the quality and cost of health care by providing information to health care providers, administrators, and patients in a timely manner.

CIS-Use Examples

figure 1. Diagram illustrating the integration profile of the Intermountain Health Care clinical information system.

In many IHC clinics, providers use an application called Clinical Workstation (CW) to enter and view data in the central data repository. CW allows providers to view a daily clinic schedule and to select patients easily. Before a physician sees a patient, a nurse may generate a patient-specific face sheet tailored for the patient’s known conditions and containing alerts and reminders. Providers document the encounter by using a variety of methods such as structured templates, macro text, direct keyboard entry, and voice recognition. While reviewing laboratory data, the physician can link directly to medical literature that describes the causes of abnormal results and provides recommended treatments. At the end of the visit, a patient’s problems are entered or updated in a common problem list, and medications can be ordered. A physician may send a message to the office staff to provide the patient with educational material before he or she leaves. Office managers and physicians can use a feature in the clinic schedule to ensure that all documentation has been completed for each encounter. Currently, in the ambulatory setting, 238 of 400 IHC-employed physicians choose to enter prescriptions into the computer, and nearly 100 physicians enter patient problems into the computer. The rate of physicians’ data entry in the clinic setting almost doubled in 2001.

Radiologists working within several IHC hospitals have access to an application that allows them to view relevant information from the HELP database while completing their notes. This application can be used to review the results of previous examinations quickly. With the availability of digital images at the workstation, radiologists can also view images as they complete their documentation. In 2002, IHC is scheduled to be nearly filmless in its largest hospitals, and all digital radiological images will be stored centrally for viewing anywhere in the network. There are links to these images from the radiologists’ narrative reports, allowing them to review a report while using a web browser to see and manipulate the images. Voice-recognition technology is allowing radiologists to enter and sign their reports at the time they read the film. Natural-language processing of radiology reports is being used to detect findings (such as pneumonia) in order to drive decision-support systems.5-10

The HELP system has long been recognized as one of the most complete inpatient documentation systems in use today. Using this system, clinical staff can keep track of important nursing information such as vital signs and medication administration. Physiological monitoring devices automatically provide information to the HELP repository through a medical information bus. As clinicians order antibiotics, a sophisticated application assists them in choosing the correct drug and dosing regimen. A robust decision-support system monitors all data as they are entered and can generate alerts, reminders, and suggestions. For example, the system can warn the user of the presence of nosocomial infection, can issue drug-laboratory alerts, and can detect inappropriate (or omitted) antibiotic prophylaxis.11-13

Physicians at IHC’s four neonatal intensive care units helped to design a specialized information system that uses the central data repository and applications available through the CW to document the care provided to their patients. Through the use of structured data-entry templates, the physicians are beginning to collect a common set of data. An enhanced problem-list?management tool allows them to track neonate-specific conditions, document these conditions on a daily basis (allowing day-to-day progress tracking), and perform research on their populations. Sophisticated reports can be generated that gather information entered by the clinicians, as well as laboratory results and other ancillary information.

CIS Benefits

Figure 2. Sample of the Clinical Workstation Diabetes Worksheet associate with each diabetic patient in the Intermountain Health Care System.

IHC has derived many benefits from the use of CIS. Chief among these is probably convenient access to patient data for those who have a legitimate need to see those data. By centralizing data in a single database, the CIS lets clinicians view all patient information efficiently using applications provided on computers at the point of care. More than 12,000 hospital-based providers and 700 clinic-based providers access data each day. Physicians typically cite the ability to view data entered at other facilities as one of the key benefits of using the CIS. A web-based results review application allows authorized clinicians to view data anytime and anywhere, improving the quality and timeliness of care. An audit trail indicating who has looked at which data is maintained to ensure that only clinically relevant data are accessed.

An important requirement for a central data repository is the use of a single, unique identifier for each patient. IHC invested considerable resources in developing this capability, which is known as the enterprise master patient directory; today, all patients in the system can be uniquely identified. Each IHC facility is allowed to keep its own identifier for its patients according to local needs. These identifiers are then mapped to the enterprise master identifier. Restraining registration clerks from creating duplicate entries for a single person is facilitated, but not entirely precluded, by automated matching logic. Thus, an episode of care consisting of encounters at several facilities can still be tracked easily. For example, a patient seen at an outpatient clinic for cough, shortness of breath, and fever may have samples for sputum and blood cultures taken. While these specimens are sent to a central laboratory for processing, the patient may be referred to a local radiologist for chest radiography. The radiologist can view the primary care physician’s examination notes while performing the radiology examination. Several days later, the primary care physician will note, in the central data repository, that the laboratory results have returned and that the radiologist’s note is available. Very quickly, a diagnosis can be made, past medical history can be reviewed, and the appropriate plan can be formulated.

Another benefit of the CIS is that data are organized and legible. For instance, all laboratory data can be grouped together for easy viewing. These data can be reformatted easily in a variety of ways; for example, the system can display laboratory results graphically so that users can view trends.

Links to the medical literature allow clinicians to review relevant information concerning patient-specific conditions. By providing these links directly within displayed clinical information, the system can save research time for providers while giving them access to the latest medical data. IHC is experimenting with new interfaces that will allow providers to access appropriate medical content within two mouse clicks for the majority of their needs.

Integrated alerts, reminders, and suggestions provide immediate help to overworked clinicians. It is generally understood that it is impossible to stay up to date on all the latest medical information, and that even information that a clinician knows can be lost in the overwhelming tasks of day-to-day practice. By being provided with unobtrusive (but clinically relevant) alerts and reminders, the clinician can immediately benefit from both the collective knowledge of other professionals and the routine operation of the CIS. For example, a diabetes work sheet that is generated at the time of a patient’s visit to an IHC clinic and placed on top of the patient’s record can provide the clinician with a reminder to perform an overdue retinal examination.

Another benefit derived by IHC from its CIS is the availability of data for clinical research and for projects promoting quality assurance, cost savings, and better service. For instance, use of the CW at the point of care for clinical data entry has decreased the need for (and cost of) transcription significantly without decreasing the productivity of clinicians. An examination of IHC clinic operations showed that the average transcription cost per relative value unit dropped from $2.50 to $0.20 at one clinic when six physicians began to enter data directly into the computer. In addition, analysis has shown that radiologists’ use of voice recognition to complete examination notes has significantly improved the availability of their reports in the emergency department, where timeliness is critical.7 Likewise, physicians who use the CW to enter progress notes directly complete over 88% of their documentation on the day of the examination.

Use of an integrated medication-ordering application has decreased the time needed to complete this task because physician-specific lists of medications allow one-click selection of common prescriptions. Patients benefit from this technology because the ordering program can then print a legible prescription that can be taken to any community pharmacy or can be sent directly to a clinic-based pharmacy for immediate filling. Physicians benefit the next time the patient asks for a prescription renewal because they do not need to write multiple prescriptions by hand.

CIS Obstacles

Although IHC has been successful in integrating information systems into clinical practice, considerable obstacles were encountered, many of which remain today. One of the primary obstacles to a successful CIS implementation is the disruption that it may cause in current clinical practice. Asking physicians to enter data into the computer can significantly change their normal routines, particularly if they are accustomed to dictating clinical notes. Features of the CIS that can decrease wasted time, improve reimbursement, and aid physicians in making decisions can overcome this barrier. Frequently, it is the partners who cover for them on nights and weekends who encourage physicians to use an electronic patient record because it allows the partners, or the clinicians in the emergency department, to make better decisions. Quite often, though, the benefits of a CIS do not accrue to those entering the data (as when decision support is used to lessen the cost of prescriptions or to recommend monitoring instead of further testing). In these cases, the cost benefit goes to the payer, while the clinician who is doing the data entry and analysis may see his or her reimbursement decline.

A CIS tends to require significant capital investments, which can be hard to justify in a formal manner. Few analyses can demonstrate a direct, short-term return on investment (ROI). IHC’s ability to decrease, and in some cases eliminate, transcription costs and file clerks at clinics helped gain management support for the CW. Through the use of an enterprise data warehouse (EDW) that consolidates clinical, financial, and business data, a more thorough, long-term analysis of quality and cost improvement has allowed IHC to perform a better analysis of the impact of various information systems. An organization cannot improve what it cannot measure. This may be the principal reason that so many organizations have been unable to demonstrate a positive ROI for information systems: the appropriate measurements cannot be made easily. Through the EDW and through an attempt to define measurement criteria before systems are implemented, IHC is improving its efforts to justify CIS investments.

Another significant obstacle to a CIS concerns privacy. While a centralized patient record with comprehensive viewing applications allows the provider to find important clinical information more efficiently, it may also allow the inappropriate viewing of patient records. On the other hand, an advantage of electronic information access is that, through the use of strong authentication, all information access may be tracked. Regular record audits, whether manual or automated, help ensure that inappropriate access is decreased. A strong organizational policy concerning patient privacy, along with warnings displayed as users access the system, can also help. In addition to these measures, IHC controls access to patient information by verifying a relationship between the CIS user and the patient for whom the user is accessing data. Providers may have the ability to override this restriction if no relationship is found, but additional auditing measures are then applied.

The architecture of current vendor applications can prohibit complete integration. Some vendors tend to create stand-alone applications that do not work well with other applications. Each vendor may use proprietary naming conventions for data and implement completely different storage methods. Often, in the past, vendors relied on specific hardware implementations, making it difficult for health care organizations to consider alternate implementations. Some organizations recognize that no single vendor can address all their information needs. IHC has attempted to address these vendor issues through several measures. First, the central data repository was designed to have a very robust, flexible data model, allowing many types of data to reside in one place. A health-data dictionary was designed to contain a complete, consistent medical vocabulary, as well as to allow the mapping of other terminologies (such as those used for inpatient and outpatient procedural coding). An interface engine collects information from a variety of sources, translates codes using the health-data dictionary, and transforms data into the proper form for the central data repository. Over 60 different sources currently are linked to the central data repository through the interface engine. IHC also demands that new applications support interface standards such as HL7, and that architectures meet enterprise standards. As IHC’s experience has shown, key enterprise architectures will be with us for 20 to 30 years, and they must be robust enough to accommodate changes in any one part of the system.


IHC has been working on computer-based medical records for the better part of 4 decades. It still has paper records in its hospitals and clinics. Until recently, IHC provided data to physicians without asking them to enter data directly. Clerks, transcriptionists, and nurses entered data, and they were also obtained it from automated sources such as laboratory equipment and monitoring devices. As the breadth of data contained in the patient database has increased and human-computer interfaces have improved, physicians have become more willing to enter data; several of them are now working to eliminate paper from their office.

IHC feels strongly that good information systems, and the process improvements facilitated by such systems, can alter the quality of care. Recent achievements at IHC have included lower postinfarction cardiac mortality rates and year-to-year improvement in blood-glucose control among diabetic patients. Professional users cite the role of information systems in these accomplishments.

Scott P. Narus, PhD, is a senior medical informaticist, Department of Medical Informatics, Intermountain Health Care, Salt Lake City.

Paul D. Clayton, PhD, is chief medical informatics officer of the department.


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