• February 2007 FEATURE ARTICLES •
Clinical Data Repository
A Clinician-Centric
Medical Results Viewer
Clinician feedback played a key roll in one not-for-profit healthcare organization’s development of a Web-based application for secure access, viewing and delivery of patient data, radiology images and lab results.
By Jason M. Kreuter, Ph.D. and Peter Basch, M.D.
MedStar Health is a not-for-profit, community-based
healthcare organization comprised of 25 integrated businesses, including
seven major hospitals in the Baltimore/Washington area. The hospitals,
which include both teaching and community facilities, are Franklin
Square Hospital Center, Good Samaritan Hospital, Harbor Hospital, and
Union Memorial Hospital in Baltimore; and, Georgetown University
Hospital, National Rehabilitation Hospital and Washington Hospital
Center in Washington. MedStar Health, like many healthcare systems,
developed from a series of healthcare mergers and acquisitions. The
resulting large number of healthcare applications from a variety of
vendors made for a challenging environment in which to find technology
solutions that would work well enterprisewide.
webAzyxxi is a Web-based clinical results viewer used by more than 2,600
clinicians to access the MedStar Health Azyxxi Clinical Data Repository,
the database foundation of the Azyxxi medical information system
(recently sold to Microsoft Corp.), which was created by Mark Smith,
M.D. and Craig Feied, M.D. Ph.D., at MedStar Health’s Washington
Hospital Center and the National Institute for Medical Informatics. The
Azyxxi Clinical Data Repository collects laboratory results, discharge
summaries, radiology images (static and full-motion), photographic data,
and all other medical data from all MedStar Health hospitals and stores
it in a Microsoft SQL Server database (Figure 1). The Azyxxi data
repository was designed and built in conjunction with the Azyxxi client,
a traditional MS Windows client-server application.
Evolutionary Pilot Growth
In August 2003, webAzyxxi was launched as a 200-user pilot project at
Washington Hospital Center. The goals of the pilot were twofold: 1) Test
Web-based remote access to MedStar clinical data; and, 2) Test the
viability and security of remote access to MedStar hospital clinical
data using two-factor authentication without the use of a VPN (virtual
private network). The pilot was a joint project between MedStar e-Health
and Washington Hospital Center Department of Informatics. This first
version of webAzyxxi was created by the Washington Hospital Center
Department of Informatics led by Smith and Feied. The National Institute
of Medical Informatics handled the application development and
refinement and e-Health was responsible for the pilot implementation.
Due to clinician demand at Washington Hospital Center, the pilot was
allowed to expand beyond the initial 200 users in May 2004. Washington
Hospital Center’s off-site access to medical data was then supplied via
an antiquated “green-screen” application. As news traveled through
word-of-mouth that webAzyxxi offered an attractive alternative to the
green-screen, more and more clinicians were anxious to gain access.
However, with clinician demand to expand the pilot came user feedback
requesting an increase in the limited data set webAzyxxi currently
accessed.
The first version of
webAzyxxi had a select set of medical data (e.g., labs results, patient
registration data, limited images, ECGs, medications and past medical
history) and clinicians were demanding more. To meet this demand, in May
2004,
e-Health hired a full-time developer to expand webAzyxxi’s capabilities.
At that time, e-Health decided that in following their goal of
clinician-centric technology, all new functionality in webAzyxxi would
be developed according to a product enhancement roadmap that was largely
based on clinician feedback. Both webAzyxxi’s capabilities and user base
rapidly expanded in 2004. Figure 2 shows the number of users over the
entire history of the pilot.
Continued Expansion
In the summer of 2004, as webAzyxxi’s functionality expanded, clinicians
across the MedStar enterprise began requesting that the webAzyxxi pilot
expand to all MedStar Health hospitals. While webAzyxxi was capable of
accessing the other MedStar Health hospital data in the Azyxxi Clinical
Data Repository, webAzyxxi 1.0, which was initially designed to be a
single hospital application, would require seven individual
installations to support all MedStar hospitals. In the long term,
maintaining seven sets of code with a three-person team would be too
large a task to manage.
However, due to the demand, senior leadership within MedStar IS chose to
expand webAzyxxi 1.0 to the remaining MedStar hospitals, along with all
the support ramifications. While simultaneously completing the
expansion, eHealth designed and built webAzyxxi 2.0 with all new
functionality that would have multi-hospital support at its core. In
October 2005, the last of the seven MedStar hospitals was added to the
pilot; it had taken less than ten months to expand webAzyxxi 1.0 to
MedStar’s six additional hospitals.
In January 2006, two months after completing the webAzyxxi 1.0
expansion, webAzyxxi 2.0 was released with a completely new code set
that allowed one installation to access seven different hospital data
sets, resulting in a dramatic reduction in the support effort. The
webAzyxxi development group consists of two full-time developers and one
part-time medical database administrator. At the time of this writing,
webAzyxxi has more than 2,600 users and has become the primary MedStar
application for accessing patient data offsite, replacing the
green-screen applications at Washington Hospital Center, as well as
another vendor supplied Web-based medical results application at the
MedStar Baltimore hospitals.
Security and Functionality
First Generation—webAzyxxi 1.0: The first iteration of webAzyxxi was a
Microsoft ASP-based application that required the use of the Internet
Explorer (IE) Web browser. The Microsoft IE requirement was due to the
application code style and the USB security key Aladdin eToken, which
originally only supported MS Windows when the pilot began in August
2003. The Aladdin eToken, combined with a user’s password, provides
two-factor authentication for webAzyxxi. To remain security device
agnostic, webAzyxxi does not use any proprietary security technologies
except the actual hardware device. The benefit of this design enables
webAzyxxi to support additional authentication security technologies in
the future.
Second Generation—webAzyxxi 2.0: The small webAzyxxi development team
had to continue to add functionality to webAzyxxi 1.0 to satisfy ongoing
user demand, while rebuilding the original application. As a result, all
new functionality in webAzyxxi 1.0 was written in Microsoft C#, utilized
Ajax as appropriate, and was built to support multiple hospitals, and to
work with any modern Web browser and operating system. In this way, the
mission-critical features most requested by clinicians could be added
quickly to webAzyxxi 1.0 without the need to continue a code set that
would not meet the long-term requirements of minimal support effort and
maximum flexibility. Eventually, all existing webAzyxxi 1.0 screens were
rebuilt using the new design methodology and, in January 2006, webAzyxxi
2.0 was formally released as a single application capable of
simultaneously supporting multiple hospitals.
Clinician Needs Drive Improvements
webAzyxxi 1.0 was originally designed to be encounter-centric, rather
than patient-centric. While this organization and display of data made
sense for physicians in an emergency department (ED) setting (for which
Azyxxi was originally designed), it also led to the same patient being
listed multiple times in a “find” result or in a location list. As webAzyxxi was used more and more by non-ED clinicians, having the
multiple listings for the same patient caused confusion. The solution
was to: 1) Use the patient medical record number that was unique to each
MedStar Azyxxi hospital rather than the encounter number; and, 2) Set
the SQL statement attribute to “distinct” in order to return unique
values (i.e., not having already been selected) regardless of the number
of encounters for that patient.
Therefore, a search for patient John Doe would return all the John Does
with unique medical record numbers across all seven MedStar hospitals.
While this does not address the issue of a lack of a master patient
index across all MedStar hospitals, it does satisfy the clinician demand
to reduce the number of repeated patient names displayed for a
find-patient search within each hospital.
Another key change in webAzyxxi 2.0 was the creation of a single
database comprised of all patient records from all seven MedStar
hospitals, approximately 7 million patient encounters. A primary reason
for this change was the fact that unlike users of the in-hospital Azyxxi
client, a significant number of webAzyxxi users were accessing patients’
records from a non-hospital location (e.g., home or private practice).
Nearly one in six MedStar clinicians are privileged at multiple MedStar
hospitals—17 percent of active medical staff is credentialed at more
than one MedStar hospital—and 10.5 percent of MedStar Health patients
get services from multiple MedStar facilities. The remote use of
webAzyxxi meant that these multi-hospital credentialed clinicians needed
an easier way to retrieve data on their patients at the different
MedStar hospitals.
To meet this need, the webAzyxxi team developed a mechanism for a
multi-hospital, patient-centric search across all seven MedStar
hospitals, or any combination of the user’s choosing. The new combined
webAzyxxi database enabled not only instant switching among hospital
data sets, but also a rapid patient “find” function (often under 5
seconds) across multiple hospital patient encounter databases. [Note:
This feature has been built, but not yet enabled, pending approval by MedStar clinical and executive leadership.]
Summary
webAzyxxi has become an integral part of medical practice at MedStar
Health. As a modern, component, object-based, three-tier
Web-application, webAzyxxi 2.0 is capable of rapid expansion through the
introduction of both enterprisewide and per hospital functionality. As
it is 100 percent client platform agnostic, webAzyxxi is capable of
supporting both today’s operating systems and tomorrow’s healthcare
devices with embedded Web browsers.