The Right Mix

Technology has made a world of difference in transforming Northwood Health Systems, a behavioral healthcare provider serving the poor and indigent in West Virginia, from a moribund institution on the brink of bankruptcy to an efficient organization with sound finances and high quality of care.

That transformation, which began a decade ago, accomplished much in the first several years through development of an award-winning electronic medical records (EMR) system, a custom-designed clinical scheduling system, electronic digital signature capabilities and an impressive videoconferencing and telemedicine network. By 2005, the investment of a few million dollars into information technology had contributed to remarkable improvements in Northwood's operations, profitability and quality of care.

But the transformation was incomplete. There was still opportunity for improvement. In the last few years, we have made the system better through a series of improvements in data management, including centralizing data management, streamlining the transport of data and making the storage of data more secure and functional. To appreciate what these changes have meant to the organization, you must understand what led to them.

Taking Down the Network

In early 1997, just before Pete Radakovich took over as Northwood's president and chief executive officer, Northwood had fewer than a dozen functional computers for 570 employees at 20 locations, an obsolete central computer and a workforce that was computer-illiterate. Our idea of data management was shuffling hundreds of thousands of pieces of paper as they were faxed and mailed daily from clinician to clinician and from office to office over three counties.

Through experience working in three distinctly different industries, Radakovich had learned how to use advanced technologies to help a corporation achieve its mission. Radakovich instilled in Northwood's organization a philosophy, which we have followed religiously, of utilizing innovation and advanced technology in achieving our charitable mission. For us, that meant developing an IT infrastructure based on "best-of-breed" technologies from such industry leaders as Microsoft, Hewlett Packard, Cisco, Intel and American Power Conversion.

Such improvements as EMR, the clinical scheduling system and electronic digital signatures allowed Northwood to be more efficient, which both saved money and improved the quality of care. Yet despite millions of dollars of IT spending, we still did not have the right mix of technology. Radakovich recognized that we needed to be even more efficient and came to the conclusion that we had to give up on our network of hundreds of PCs

That was a difficult decision because those PCs had been integral to much of our technological transformation. But they prevented us from being as efficient as we needed to be. The root problem was that the network of hundreds of PC workstations at what were then 19 locations made data management difficult.

For example, to management's dismay, clinicians developed the undesirable habit of storing files on their PCs instead of on the network servers. By storing patients' medical records and financial records on their local PCs, they opened Northwood up to potentially serious problems in protecting the privacy of patients and HIPAA violations. We had no way of knowing what was out there, so it was impossible to know who might have been accessing those records.

It also was difficult to properly implement Northwood's records retention policy under those circumstances. Although most files were saved on remote servers that were backed up nightly, many of the files clinicians were storing on local PCs were not transferred to the servers and were not backed up at all. Since the PC hard drives lacked reliable backups, data could be lost permanently when a PC malfunctioned.

But even when the PCs functioned well, clinicians experienced delays receiving important clinical information via the network. Part of data management is the transport of data–getting information to and from end users–and using a bandwidth-intensive network of PCs made delays inevitable.

Using many local PCs across a network connecting 19 facilities taxed the network's bandwidth to such a degree that pulling up medical records sometimes slowed to a crawl. Response times were so slow that at some satellite locations it could take five minutes or more to open a patient's assessment.

A New Solution

Keeping data current on hundreds of PCs at 19 locations spread out across three counties also meant that once a week–sometimes once a day–technicians would have to save data on CDs and physically drive to each location to load the data on that location's server. In the meantime, until the next update occurred, clinicians would not have access to the patients' most updated medical records, compromising our goal of delivering the highest possible quality of patient care.

For a brief period, we tried to solve that problem by using phone lines to download the data overnight to the servers at satellite offices. But transmissions sometimes failed during the night, again leaving clinicians without updated medical records information. Obviously, that made it harder for clinicians to provide the highest quality of care and increased Northwood's potential liability.

Additionally, with many potential points of failure across the network of PCs, it could take hours to diagnose computer problems. Even regular onsite maintenance and routine software upgrades required hours of technicians' time–much of it spent traveling to remote locations outside of normal business hours.

By early 2005, Radakovich made the decision that our network of PCs, despite its great contribution to Northwood's turnaround, needed a significant overhaul. He and members of our IT department decided on "thin client technology," which is used in other industries instead of PCs. Thin clients are network computers without hard-disk drives. They are smaller than PCs and have fewer operating parts, because data processing occurs on a central server, not on the thin client itself. Because they do no processing, thin clients do not contain such potential failure points as fans and hard drives.

Centralizing the Data

The implementation of the new thin-client system began with the purchase of Microsoft Windows Enterprise Server 2003 software and three Hewlett Packard Prolight DL380 servers. After we conducted an inventory of all software needed by Northwood clinicians and other employees, technicians installed that software on the servers and then transferred all files from the local PCs to the servers. The next step was for Northwood to install hundreds of thin clients–one to replace each PC workstation. Those installations required two technicians–one with more than 15 years of experience–working fulltime for more than six months.

Switching to a network of thin clients, which was completed in late 2006, did wonders for Northwood's operations. Now, all data are centralized on 27 state-of-the-art servers at the corporate headquarters. Clinicians can view data quickly and easily from any of Northwood's 19 facilities. In other words, a staff member has the same desktop experience–with quick retrieval of data–no matter where that person is working at any particular time.

The new Hewlett Packard storage area network makes data available to more than one server simultaneously. This creates redundant backup among servers, called clustering, and provides fail-over capability. In other words, if a server goes down, the end-user is routed to a different server, which has access to the same information on the storage area network. This ensures that information needed for important clinical decisions is always readily available to clinicians, even in the case of a server malfunction.

With centralized data management, satellite offices always access the most recent data directly from clustered servers at the main office. Managing the data this way provides end-users with real-time, up-to-date data without the cost of physically transporting data to satellite offices.

Centralization of data management also ensures that you can account fully for data files. All data are totally secured and completely backed up. This ensures that Northwood can maintain the privacy of its patients and can more efficiently and effectively implement our record retention policy.

Unlike PCs, which require large quantities of data to be pulled back and forth across the network, thin-clients merely reflect images from the main server. The server handles all the data processing, so much smaller amounts of data go back and forth across the network. This is especially important at facilities in rural areas with limited broadband capacity. With PCs, the transfer of data to those rural locations was painfully slow, but the thin clients with their lower bandwidth requirements work smoothly and efficiently.

Streamlining Data Management

Dealing with defective thin-client terminals is much simpler than repairing PCs. When a thin client fails, a clinician can quickly take a backup unit from storage and replace the defective unit. The clinician can get back to work right away and not have to wait hours for a technician to show up, diagnose and fix the problem.

When technicians need to conduct such routine tasks as upgrading software, they can do it in a matter of minutes from Northwood's corporate headquarters. They no longer need to spend weeks installing new software on hundreds of PCs spread across 19 locations and three counties.

Clearly, improved efficiency is one of the advantages of a thin-client system. Clinicians are more productive, because they spend less time waiting on data and forms. IT personnel can concentrate on development and operational enhancements, which improve the organization's return on investment, instead of being consumed by repetitive PC updates and maintenance. Northwood no longer needs a fulltime IT technician dedicated to fixing computers and assessing network problems. Even when thin clients need to be repaired, there are only a few potential failure points to examine. This stands in stark contrast to our network of PCs, which had many potential points of failure and maintenance.

With our new centralized data management system, it is easy for management to monitor what work has been done and what work still needs to be done. For example, the minute a patient's treatment plan is complete, any Northwood employee with authorization can access the file. That efficiency helps improve clinical care, as well as cash flow.

Data Integration

We also realized that centralizing our data management provided a great opportunity to integrate data and other systems. Previously, our phone and voicemail system, computer network and videoconferencing connections were all disparate systems with separate maintenance points. When we switched to thin-client technology, we also adopted a Cisco Voice over Internet Protocol (VoIP) system. The Cisco system merged our disparate systems, creating a single voice, video and data network.

This improved data management by integrating the various types of data into one network, all sharing the same bandwidth. The primary advantage of integrating voice, video and data traffic into one network is that we no longer need to assess, monitor and maintain several different systems. We manage only one system, which actually provides more functionality than the original three separate systems.

Also during that time, Northwood significantly modified its databases. Previously, Northwood used a primitive and proprietary database to store information on patients, employees, services and other aspects of its operations. This proprietary database was very inflexible. The ability to develop reports from the database was quite limited and could only be done by a few employees within the organization.

Since then, Northwood has migrated to Structured Query Language (SQL) databases, which are more standard in other industries outside of behavioral healthcare. SQL is a very flexible platform, which enables a wide range of employees to create their own reports via a Web-based interface. This new database platform has enabled Northwood's clinicians and managers to have quick and easy access to important data.

Another change Northwood has made to improve the way employees manage data is the implementation of dual, flat-panel monitors. Each pair of monitors is set up to function as one large computer desktop, permitting employees to have more documents visible simultaneously on their computer screens. Documents can be moved from one monitor to the next, or data can be moved from one document to another seamlessly and efficiently.

Positive Changes

Northwood's technological transformation is not solely responsible for the organization's turnaround, but it has played a very important role. A decade ago, when the organization was in its darkest days, Radakovich had to renegotiate contracts with some vendors, drop other vendors, eliminate some positions and cut waste throughout the system. He also had to change the philosophy of our organization from that of a social service agency dependent on governmental funds to that of a business with a strong social conscience, determined to become a world-class healthcare provider.

These changes have taken Northwood from facing a debt of more than $5 million with operating losses of more than $80,000 a month in 1997, to the financially strong organization it is today with annual revenue of about $23 million. Quality of care has also improved, and it is not unusual for Northwood to get perfect scores on state regulatory audits in recent years.

I saw what the organization was like when it was on the verge of collapse, so it is especially heartening to walk the halls of Northwood today, seeing clinicians hurrying to their next appointments and managers discussing day-to-day operations with the intensity of military strategists. And I'm grateful to work with a CEO who oversees this operation with the business acumen of a Fortune 500 executive, coupled with a compassionate touch rarely seen in the corporate world. Not only has Radakovich saved Northwood in the present, but he has also spent countless hours teaching and transferring his knowledge to those of us he will leave behind. In so doing, as with a child, he has made provision for Northwood's future success as well.

Much of the improvement made by Radakovich was in place even before the switch to thin-client technology and the centralization of data management, so it would have been easy for him to be satisfied with those gains. However, we are fortunate that Radakovich's philosophy has always been one of continuous improvement, settling for nothing less than world-class performance. Centralizing our data management, streamlining the transport of data and making the storage of data more secure and functional have helped us meet such standards.

Mark Games is chief operating officer for Northwood Health Systems, based in Wheeling, W. Va. Contact him at MGames@corp.northwoodhealth.com.