Using VA Software to Create an Integrated Clinical Information System

Transcription

1 Using VA Software to Create an Integrated Clinical Information System in Non-VA Medical Facilities R.M. Kolodner, M.D.* R.L. Morton** D.R. Fowler, M.D.* D.S. Cannon, Ph.D.* R.S. Stewart, M.D.** Department of Veterans Affairs Medical Center at Dallas Dallas, TX and The University of Texas Southwestern Medical Center Dallas, TX ABSTRACT This paper reports the use of the VA's Decentralized develop and maintain. The VA has Hospital Computer already invested more time Program software to integrate clinical and resources to data develop the DHCP than stored most on 3 other public sector separate computers installed in a public agencies could afford to invest themselves, and it is maintaining County Hospital. Clinical access to the data on all three systems is currently available only in limited areas in the hospital and requires the use of at least two different terminals. The linking system, written in MUMPS, has been installed on a based microcomputer located in the Outpatient Psychiatry Clinic in the facility. This linking system is designed to meet clinicians' needs for integrated clinical information regarding their patients without imposing additional load on the existing computing resources during peak working hours. Patient management, laboratory, and pharmacy information from non-mumps systems will be automatically downloaded each night to the microcomputer for patients scheduled in the clinic. The linking system will allow ad hoc queries on aggregate patient data related to patient care and to quality assurance which can be run during non-clinic hours. The microcomputer runs in multiuser mode with terminals located in provider offices in the clinic. INTRODUCTION In this paper, we report our experience during the first phase of a project funded by the Hogg Foundation to develop a decision support software system to be used by Mental Health professionals in public sector facilities. The project builds on a foundation provided by the existing, public domain, clinical information system developed by the Department of Veterans Affairs (VA) under its Decentralized Hospital Computer Program (DHCP). The first phase generalizes and tests the administrative, laboratory, and pharmacy software, along with the VA's Mental Health software, for use at non-va facilities. The next phase involves developing and installing DHCP-compatible clinical decision support software at the Dallas VA Medical Center. This report summarizes our progress in phase one -- the test of the adapted software at a non-va, public sector medical center. The success of this first phase can have far-reaching implications for the cost-effective dissemination of clinical information systems throughout the public sector. Although the project concentrates on using the system in Psychiatry, the integrated clinical information could be utilized by other medical disciplines. Clinical information systems are complex and expensive to * Dallas VAMC and UT Southwestern ** UT Southwestern and expanding this system steadily. Most available commercial systems are not only expensive to purchase and maintain, but they also do not have the clinical emphasis sought by most public health care facilities once the decision to automate has been made. Major savings can be achieved in the automation of public health care facilities if the VA software can be adapted to meet clinical needs at sites other than the VA. A consortium of public facilities could exchange locally-developed clinical and administrative software if they shared the same basic system. Software vendors could compete in this marketplace by selling compatible programs that offer enhancements and additional capabilities. The task of installing this adapted software in non-va facilities differs considerably depending upon whether or not the test site already has automated information systems in place. For this project, we chose to modify the DHCP software so that it could be installed at sites having existing computer resources, rather than placing it at sites having no previous automation. The reason for this choice was a pragmatic one -- all existing public-sector mental health facilities in the area have automated administrative information systems in place. Some also have clinical information systems. The VA software enhances these existing systems by providing a cost-effective method for improving the clinical accessibility and utility of the existing data. The Psychiatry Outpatient Clinic of Parkland Memorial Hospital was chosen as the alpha test site to accomplish this task due to its close proximity, staffing by members of the UT Southwestern Department of Psychiatry, technical support from Parkland's Information Systems staff, and eager support by the clinical and administrative staff in the clinic. Parkland, like many health care facilities, has the problem of using separate departmental computer systems that do not coordinate with one another, 4ue to the historic circumstances by which they were acquired. this can limit access by clinical staff to the information they need, or require them to log on to different systems, using different terminals, in order to access all of the relevant information about their patients. The VA DHCP software can be used to integrate the data stored on these separate systems into a single system and then disseminate this combined data in a cost-effective manner to health care providers. Work by investigators developing integrated hospital clinical systems has documented that clinical systems can improve the quality and efficiency of the care delivered to patients (1,2,3], and their efforts provide themodel for our approach as we develop the generalized, exportable software. U.S. Government work. Not protected by U.S. copyright. 644

2 BACKGROUND In this section, we will provide a brief background on the VA's DHCP system, since it forms the basis of our project, and explain why it has more clinical emphasis than most commercial systems. VA DHCP In 1978, plans were drawn up to develop a VA-wide clinical information system that would be based upon hardware and software resources to be located at each VA facility. In 1983, Congress charged the VA with the task of implementing this system, formally named the DHCP. Since that time, the VA has installed the DHCP systems at 169 facilities nationwide. All of these VA sites run software to support the functions of Medical Administration (patient registration in all of the facilities, admission/discharge/transfer for inpatient, and scheduling for outpatient functions), Laboratory, and Outpatient Pharmacy. Eight additional modules are scheduled for installation at all sites over the next two years, including software to support Radiology, Surgery, Nursing, Dietetics, Mental Health, Order Entry/Results Reporting, and additional administrative and management functions. Software is currently being developed for a variety of other services and functions. These new applications are being tested and used at local VA facilities, depending upon their interest and the available resources they have available beyond those necessary to support the required modules. From its inception in 1978, the DHCP effort has been guided by four basic principles. First, the software has to be independent of specific vendor hardware. This is achieved by developing all software in a stable, vendor-independent computer language and by requiring programmers to adhere to standards and conventions in the programs they write. All DHCP software is written in the MUMPS computer language, which has a standard defined by the American National Standards Institute. This standard computer language runs as a stand-alone operating system on hardware from a wide selection of manufacturers. Furthermore, the MUMPS language is supported by a broad range of operating systems, including MS-DOS, UNIX, XENIX, VMS and VM. The VA has established standards and conventions for all programs written for use in DHCP, including file structures and program design. Second, the information system is designed as a coordinated group of modules that not only meets the needs of individual departments but also facilitates the exchange of data between these modules to be used for multiple purposes. This principle is accomplished by the use of a database manager at the heart of the VA's system and by a data dictionary for all data elements. Third, software development is guided by the users themselves. This principle is fulfilled by actively involving VA users in the process of software development through special interest user groups that have been established in each major department. In addition, several user groups (Clinical Record, Order Entry/Results Reporting, Quality Assurance) have a multidisciplinary composition in order to provide integration across the individual modules. Fourth, since VA facilities differ, the software must be flexible enough to run in a broad range of institutions. The VA medical system consists of 210 facilities including Nursing Homes, Domiciliaries, stand-alone Outpatient Clinics, and inpatient sites ranging from small 78 bed Hospitals up to 1164 bed, tertiary care Medical Centers. This flexibility is provided by building the adaptive mechanisms into the software (the "source code"). DHCP software can be tailored by each site to meet its needs, but these adaptations merely adjust files and site parameters. They do not modify the software routines. This approach allows modules with new functionality to be added easily and updates of existing modules to be installed without requiring that the site-specific installations be repeated each time. The VA software has maintained a clinical emphasis due to the nature and funding of the VA health care system. Since the VA budget is a "fixed pie" that is divided up among VA sites, "reimbursement" has been based on workload documentation rather than standard "billing" procedures used in other medical settings. Thus, although the VA software facilitates the daily operations of each department for which software is specifically developed, such as Laboratory, Pharmacy, and Radiology, the emphasis is not on the administrative and billing aspects. Instead the system has a stronger clinical component than in many commercially available hospital information systems. Moreover, the direction of future VA software development appears to heavily favor a clinical emphasis -- assisting the "front-line" clinician. With notable exceptions [4,5,6], most other hospital systems have little to offer clinicians other than simple data retrieval capabilities. Few information systems besides the VA [7,8] have developed clinical data entry functions that have been implemented and accepted by clinicians at multiple sites. TEST SITE DESCRIPTION The test site, Parkland Memorial Hospital, is a 953 bed County Medical Center affiliated with the University of Texas Southwestern Medical Center. There were a total of over 7900 visits last year in the Psychiatry Outpatient Clinic at Parkland. The clinic staffing includes 12 Psychiatry residents in their third year of training, 2 Attending Psychiatrists, a Psychiatric Nurse Specialist, a Social Worker, 2 Psychology trainees, and 2 clerks. The existing state of automation at Parkland is similar to that at many other medical facilities. Three different computer systems are used in the clinical setting to support the administrative, laboratory, pharmacy, and radiology functions. These systems were acquired over a period of time, and each was chosen because it met a specific need at the time it was purchased. The first system, the IBM Patient Care System / Applications Development System (PCS/ADS), is installed on an IBM mainframe and handles registration, clinic scheduling, hospital admission/discharge/transfer, and combined order entry, charge entry and billing functions. A radiology system was developed locally on the IBM system and consists of order entry and results recording functions. The second system, a Community Health Computing laboratory system, runs on STRATUS hardware in the laboratory. An interface connects the laboratory system to the IBM system to 645

3 enable order entry from the hospital system to the laboratory system and results reporting from the laboratory system to the hospital system. A nightly tape of billing information is provided by the laboratory system to the IBM system. These processes serve two purposes. First, although the laboratory data is stored redundantly for a shorter period of time than on the STRATUS system, the data stored on the IBM mainframe is accessible at a greater number of sites throughout the medical facility. There are 1 or 2 terminals connected to the IBM system on every ward and in every clinic, while only 17 terminals connected to the Laboratory system are located in clinical areas outside the laboratory. Second, the information transferred nightly by tape from the laboratory system is used to generate patient and thirdparty payor billing by the IBM system. A General Computer Corporation pharmacy system, the third system, runs on a stand-alone NEC minicomputer. The system has a total of 13 ports, with only 3 terminals located in clinical areas outside of the Pharmacy. There is no direct connection with the IBM system. A computer tape is generated by the Pharmacy system every night and then read into the IBM system to generate billing information. Thus, a substantial amount of clinical information exists in electronic form at the test facility. However, this information is not integrated in a format useful to clinicians. Moreover, all of the information is not accessible electronically to clinicians throughout the hospital, and its availability is restricted by the relatively few terminals in the wards and clinics compared to the number of health care providers who work in each area. This situation is common in many medical settings. Some investigators addressed this latter problem by developing paper-based flow sheets for distributing this computerized information to clinicians at the time the patients are being treated. More recently, they have explored the use of individual workstations [9]. The first phase of our project is designed to develop and assess a cost-effective method for integrating clinically useful information from existing information systems. This integration would not only capture the available data, but would disseminate all the data to the "front-line" clinicians through a single terminal located in each clinicians' office using software that would facilitate their daily patient care activities. IMPLEMENTATION GUIDELINES For this project, we chose to adhere to several key guidelines in order to gain maximum user acceptability, to control any additional workload on the existing computer systems, to keep costs low, to minimize software development, and to maintain the generalizability of our efforts. The guidelines and their rationale are as follows: 1. Perform all the integrative processing on a separate CPU from the existing computer hardware. The current hardware systems perform the current functions adequately but have a minimum of excess capacity. The project would not be feasible if new purchases were required for these mini- and mainframe systems. 2. Start with the VA's DHCP software. The software is free, since it is in the public domain. It covers most of the major hospital clinical functions, with more software in development and scheduled for release over the next two years. The existing software is maintained and updated regularly through procedures in the VA. 3. Follow software standards, naming conventions, and file structures compatible with the VA standards. By adhering to the standards, the system will be able to immediately incorporate additions or enhancements released by the VA or its collaborating agencies. 4. Use the basic VA user interface and security procedures. Using the VA's "Kernel" to handle these issues will preclude the need to redevelop these functions while ensuring adequate software security. 5. Allow the clinical user to define the most important functional priorities of the system, and involve the users in an iterative development of any new software necessary to meet their needs. Meeting user needs is an important factor in successful design and implementation of a new clinical system. [10] 6. Provide adequate user education. This is another important factor in achieving a successful implementation. [10] 7. Let the new system handle most data inquiries to the other computer systems. Most of these inquiries can be performed at non-peak hours to minimize the adverse impact on the existing computer systems. For inquiries during routine working hours, the user will be "passed through" the MUMPS system and logon to the IBM mainframe for immediate data needs on a non-scheduled patient. 8. Enable the users to perform both predetermined and ad hoc queries on the patient data present in the new system. New uses for the data and new functionality can be defined by the users if they have the ability to "play" with and explore the data. These capabilities are supported in the VA software through the search and reporting functions built in to the database manager (FileMan) that is an integral part of the DHCP system. REPORT OF PROGRESS As of August, 1989, we have completed the installation of the public domain release of the VA software onto a microcomputer located in the Parkland Outpatient Psychiatry Clinic. This includes applications for storing and retrieving patient identifying, demographic, and scheduling information, Laboratory results and Pharmacy prescriptions. The routines are altered slightly to allow for patient look-up by medical record number (Parkland's method) instead of by Social Security number (VA's method) and to add a new password encryption method for storing the passwords in a file. Otherwise, the DHCP applications are essentially unchanged. A 25-MHz, based microcomputer with 4 MBytes of Random Access Memory and a 300-MByte disk drive is being used during this project through the generosity of Hewlett-Packard Corporation. The VA MUMPS software, 646

4 occupying approximately 50 MBytes of disk space, can support at least 20 simultaneous users on this microcomputer. In addition to CRT's for each user, one port from this microcomputer is linked to the mainframe IBM system in Parkland via an IBM 3270 protocol converter manufactured by Adacom, Inc. This port will be used to download all of the patient information from Parkland's existing computer systems beginning in September, Each night, the IBM mainframe builds a file containing the demographic, laboratory, and pharmacy data for those patients with an appointment scheduled the following day. Pharmacy data on these patients is extracted from the tape downloaded to the IBM mainframe each night. Beginning in September, this file will be transmitted automatically from the mainframe to the project microcomputer using IBM's IND$FILE protocol during the night prior to each clinic, during a period of low activity on the mainframe. After the file has been received by the microcomputer, the various data elements will be extracted and stored in the DHCP file format. Both the IND$FILE transfer and the data extraction are done in MUMPS. The data will then be retrievable using standard VA DHCP applications. These clinical data are stored in the microcomputer for use the next day by clinicians who are scheduled to see the patients. In October, 1989, we plan to have the system in routine daily use by clinical staff in the Outpatient Psychiatry Clinic, who will have terminals in their offices connected to the microcomputer. They will be issued the dual-level security codes necessary to log on to the system. VA DHCP software will be used to access patient data on the system. Limited access will be needed to the other Parkland computers during working hours for patients seen in the clinic on an emergency basis, without an appointment. We plan to meet this need by using the protocol converter. Although the primary function of the converter is to facilitate downloading of patient data from the mainframe to the microcomputer at night, this equipment can allow any of the terminals connected to the microcomputer to emulate an IBM 3270 terminal and log on to the IBM system. Thus, a clinician will be able to query either the MUMPS or the IBM database from a single office terminal. In addition to the laboratory, pharmacy, and administrative DHCP applications noted above, we will install the VA Mental Health software, adapted for use by clinicians at the non-va test site. This software includes the capability for making progress notes that can be placed in the chart, for creating problem lists, and for entering DSM-III-R and ICD9 diagnoses. These latter functions will facilitate continuity of care at those times in the future when the patients are seen without the medical chart being available. Currently clinicians in the clinic create and maintain "shadow" files, in addition to the standard medical record, to protect against those times when the chart is unavailable for clinic appointments. One requirement we have identified is the need to capture all new laboratory and pharmacy data for patients treated in the Outpatient Psychiatry Clinic. This is especially important for reviewing the results of laboratory tests ordered by the clinic physician. Rather than waiting until the time of the next scheduled appointment to review the results, this system will facilitate the physician's ability to review all of the new laboratory results available on the patients they treat. Several alternatives are being examined to identify this information on the mainframe and download it to the project microcomputer, including scanning the lab and pharmacy data for patients seen within the past week in the Outpatient Psychiatry Clinic or having the microcomputer sequentially query the mainframe, through an automated dialogue, to download and parse recent laboratory and pharmacy information. We will be choosing among the alternative solutions as our project progresses. Also, we plan to address the problem of how long to retain clinical data on the linking microcomputer system during the course of the project We want to keep the data as long at it is useful to clinicians and clinical administrators for patient care and QA purposes, and have provided adequate storage capacity to achieve this goal. A formative evaluation will be conducted during and after the project, in keeping with the developmental nature of the tasks involved [11]. Feedback from the users will be applied throughout the project to guide the evolution of the software. FUTURE DIRECTIONS Additional routines will be written (1) to perform Quality Assurance monitoring tasks that have been done until now using labor-intensive, manual methods and (2) to assist clinicians with the on-line retrieval of laboratory and pharmacy data specifically for the patients they are treating. As an example of the latter function, a physician could retrieve all new laboratory results for patients treated during the past week without having to request the data individually by patient. All new routines will be written in compliance with the VA DHCP guidelines and standards to facilitate their use and dissemination within the VA. This twoway exchange of software would broaden the base for developing new applications for this public-sector driven medical information system. Finally, we will be developing and testing DHCP-compatible software to emulate the clinical decision support capabilities that have evolved in the two noteworthy clinical systems cited earlier [4,5]. We intend to design a flexible application that can be used by the "front-line" clinicians to enter their own clinical alerts and reminders. Moreover, we hope to store the logic in a generic form that can be not only be exchanged among DHCP sites, but might lend itself to transfer to non-mumps systems. Funding from the Hogg Foundation is intended to support the design of a general system of this type. A recently funded grant from the VA Health Services Research and Development Service will utilize DHCP-compatible software at 12 VA facilities to compare the relative impact *of a specific psychiatric decision support application with that of a traditional educational program. 647

5 DISCUSSION Although conducted in a mental health setting, the project we are reporting here provides potential solutions to three problem areas in the general field of medical computing. These problems include (1) the lack of a standard, vendor-independent computing environment, (2) the patchwork quilt of incompatible computer systems often present in existing medical facilities, and (3) the inefficient use of limited public sector resources if clinical systems were to be re-created from "scratch". First, the history of medical computerization has been one of new, incompatible medical information systems being developed by investigators and vendors. This lack of standardization forces users either to stay with systems that no longer meet their needs, to switch from one vendor to another leaving behind most or all of the previous data they had gathered, or to undergo massive, costly, time-consuming conversions from one vendor's system to another. Medical users might be better served by the creation of a standard, hardware-independent, vendor-independent medical computing environment. In such a setting, vendors could compete based on the capabilities and performance of their software, upgrades in capacity could be achieved by moving smoothly from one hardware configuration to another regardless of the hardware manufacturer, and expansion in functional capabilities could be accomplished by the addition of new software modules. The VA's DHCP might help to foster a standard medical computing environment. The software is in the public domain, available free to government agencies and at the nominal cost of duplication to anyone who requests a copy. The installed base in the VA and the Indian Health Service represents more facilities, and a wider variety of facility types and sizes, than for any other medical information system. The well-defined file structures and the procedures for naming new software routines foster the disseminated development of software and the exchange of new applications among facilities running DHCP-compatible systems. The use of the DHCP software in non-federal facilities would further broaden the installed base and serve to create a larger potential market place for vendors who wish to compete in a standard medical computing environment. Second, since many medical facilities own and use multiple computer systems that communicate with one another either with great difficulty or not at all, there will continue to be the need to link data from these systems together to provide clinicians with easy access to all available patient clinical and demographic information. This project is in the process of demonstrating that DHCP software can be used to integrate the incompatible departmental computing systems that may be present in a medical facility. Our approach offers a cost-effective method for continuing to use these existing systems, as long as they meet the departmental needs, while disseminating and integrating patient data for use by clinical staff in their daily patient care activities. Third, public sector health care agencies and facilities continue to wrestle with the problem of meeting their needs for clinical and administrative information management. After surveying the available vendor products, personnel at some state and local facilities and agencies often consider developing their own clinical information systems. Indeed, some have actually begun such development. These efforts may succeed if their only intent is to create small, well-delineated databases. However, the development of a comprehensive, integrated, supportable clinical information system is a complex undertaking that is beyond the resources available within most of these organizations. The skeletons of past systems, now abandoned, and the long-term development projects that are well-behind schedule attest to the difficulties involved. Even systems that appear to be successful in the short-term usually fall short of expectations and are discarded after the person or people who were the system advocates move on to new jobs. These aborted efforts result in a waste of the limited funds available to public facilities and organizations. We believe that these efforts and resources can be better spent in collaborative ventures with other public facilities and agencies in the evolution and expansion of a common, standard, flexible clinical computing environment. This project represents one more step in this direction, extending the VA's DHCP system and the first enhancements to this system by the Indian Health Service to meet more general clinical needs in the public sector. REFERENCES [1] Barnett GO, Winickoff R, Dorsey JL, Morgan MM and Lurie RS.: Quality assurance through automated monitoring system and concurrent feedback using a computer-based medical information system. Med dare 16: , [2] McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ, Weinberger M and McCabe GP: Reminders to physicians from an introspective computer medical record. Ann ofintem Med 100: , [31 White KS, Lindsay A, Pryor TA, Brown WF and Walsh K: Application of a computerized medical decision-making process to the problem of digoxin intoxication. JAm Coi Cardiology 4: , [4] McDonald CJ: Action-oriented Decisions in Ambulatory Medicine. Chicago, Yearbook Medical Publishers, Inc., [5] Pryor TA, Gardner RM, Clayton PD and Warner HR: The HELP system. JMed Sys 7:87-102, [6] Stead WW and Hammond WE: Computer-based medical records: The centerpiece of TMR. MD Comput 5(5):48-62, [7] Barnett GO: The application of computer-based medicalrecord systems in ambulatory practice. New Engl J Med 310: , [8] Kolodner RM: Clinical computer applications for mental health treatment in the Veterans Administration system, in Clinical Care and Information Systems. Edited by Mezzich JE. Washington, D.C., American Psychiatric Press, Inc., [9] McDonald CJ and Tierney WM: Computer-stored medical records. JAm MedAssoc 259: , 1988 [10] Fischer PJ, Stratmann WC, Lundsgaarde HP and Steele DJ: User reaction to PROMIS: Issues related to acceptability of medical innovations, in Use and Impact of Computers in Clinical Medicine. Edited by Anderson JG and Jay SJ. New York, Springer-Verlag, 1987, pp [11] Rossi PH and Freeman HE: Evaluation. Beverly Hills, Sage Publications, Supported by a grant from the Hogg Foundation and by donations from Hewlett-Packard Corporation, Micronetics Design Corporation, and Arnet Corporation. We also wish to thank the clinical and administrative staff at Parkland Memorial Hospital who made this project possible, and especially the Information Systems staff for their tireless support in designing and establishing the links with the existing computer systems at Parkland. Mailing address: Robert M. Kolodner, M.D. Psychiatry Service (1 16A) VA Medical Center 4500 S. Lancaster Road Dallas, Texas