In-Depth

Taking paper out of the healthcare system

• By Lana Gates
• April 1, 2002

Application Development Trends'
2002 Innovator Awards
E-business Application Development
Honorable Mention

An Institute of Medicine report in June 2001 stated that more people die each year from medical errors than from car accidents, breast cancer or AIDS. In response, Boston-based CareGroup Healthcare System initiated a Provider Order Entry (POE) system pilot project aimed at reducing medical errors. The organization invested $2 million in the system in an effort to save lives and costs.

The system lets doctors pull patient data from a server fed by the Cache database from InterSystems Corp., Cambridge, Mass. After examining a patient, a doctor decides on an appropriate action, like prescribing a medication. POE applies business rules to double-check the doctor's decision and to determine if that specific medication and dosage are appropriate for the patient -- based on other medications the patient is taking, the patient's size or the availability of newer drugs. The doctor weighs POE's feedback, decides which course of action to pursue and executes it. POE communicates with robotic drug-dispensing machinery in the hospital's pharmacy.

The Web-based order entry system replaces all hand-written and verbal orders in the hospital. Physicians enter every medication, lab, dietary, radiology and general care order via the Web. Doctors use "both PCs and wirelessly connected Web devices such as Fujitsu table with 802.11b wireless" to enter these orders, explained Dr. John Halamka, CIO. "Palms have too little screen real estate for such an application," he explained.

Many clinicians were against using computers and thought the order-entry system would be time-consuming. In an effort to alleviate opposition, the development team assembled a guiding coalition of physicians, nurses, pharmacists and ancillary staff.

With 12,000 employees, 3,000 doctors and 9 million patients in the CareGroup system, scalability was an issue, as were performance, security and reliability. CareGroup chose the Cache database because it provided scalability, performance and reliability in one tool. "We do 900 transactions a second in our clinical system," Halamka said. "Relational databases like Oracle could not offer this transactional performance."

The Cache system runs on two HP 9000 CPUs, one of which is always on standby to prevent downtime and data loss. An EMC storage tower hosts the database, and users access the application through Web browsers. Dual-processor Compaq Web servers, triply redundant with automatic fail-over run Windows 2000 and Microsoft Internet Information Server.

The 20-person development team consisted of 11 software developers and nine application specialists, with a total of 403 years clinical experience among them. Key developers wrote the Web tools used to design the system and then trained team members in the technology before getting underway.

The project, which was scheduled to go live for 90% of the hospital's admissions on March 12, took two years and four months to complete in two phases: infrastructure development and implementation. Leadership position changes in the hospital pushed the go-live date for the project back by six months. A major relocation and consolidation within the hospital added to the delay.

Management and the user community consider the project a success. It has eliminated 50% of medication errors and takes no additional time. The key to its success, according to Halamka, was early physician involvement and training because POE is 15% technology and 85% process and organizational change.

Application profile:

Tools and Technologies:
InterSystems Cache running on Microsoft Windows NT Server 4.0 running Internet Information Server

Platforms:
2 HP 9000s, EMC storage tower, dual-processor Compaq Web servers

Development Team:
Robert Beckley, Jean Hurley, Kevin Afonso, Nan Zullo, Edna Moody, Elaine Bianco, Rebecca Stocking, Timothy Walden, Michael Monroe, Valerie Portway, Sandra Goodman, Alice Lee, Eileen Yanchewski, Mary Biagiotti, Patricia Bourie, Jane Burke, Nancy Sweeney, Fran Tripp, Marcy Wasilewski, Karen Rapuano