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Case Study: Physicians DevelopResults Viewer Amid Y2KCommotion

Janice A. Wurz, Jonathan L. Manis, MIS, MBA

ABSTRACTAmid a flurry of Y2K preparations, which included converting patientaccounting and order processing systems for six of its eight hospitals,Advocate Health Care needed to address physician complaints that thecompliant software was awkward. By partnering with physicians, infor-mation systems (IS) rapidly developed a solution that met both the needfor compliance and the demand for an easy-to-use, patient-centric clinicalinformation system. A robust, browser-based results viewer providesphysician access to information from patient accounting, order process-ing, and several clinical ancillary systems. Advocate anticipates greaterchallenges as the system is promoted to other sites and clinicalcommunities.

KEYWORDS• Physician satisfaction• Clinical results• Web-enabled• Development• Partnership• Patient-focused

Advocate Health Care, based in Oak Brook, Illinois, is the largest fully inte-grated healthcare delivery system in metropolitan Chicago and is consistentlyrecognized as one of the top ten systems in the country. Advocate has eighthospitals with 3,076 beds among its more than two hundred sites of care.More than twenty-one thousand people work with over four thousandaffiliated physicians to administer high-quality healthcare throughout theChicago area.

JOURNAL OF HEALTHCARE INFORMATION MANAGEMENT®, vol. 14, no. 3, Fall 2000© Healthcare Information and Management Systems Society and Jossey-Bass Inc., Publishers

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Advocate and Y2K Compliance

Expectedly, readying Advocate’s information, biomedical, and facility systemsfor year 2000 was an enormous and extremely complex undertaking. Forinformation systems (IS), preparing for Y2K meant visiting over six thousanddesktops and upgrading, patching, and testing hundreds of systemwide andsite-specific applications. Most significantly, preparations required conversionof the existing patient accounting and order processing systems to a Y2K com-pliant version of the software at six of Advocate’s eight hospital sites—all withinthe eighteen months prior to January 1, 2000.

In an effort to minimize resistance to the inevitable process changes thatwould result from the preparations, IS worked closely with site staff for monthsbefore each implementation of the new patient accounting and order process-ing systems. Conversions affected every hospital department; two IS teamsfocused on patient-related and clinical data processes. The project plan encom-passed a consolidated hardware platform, data conversions, downtime con-siderations, training for thousands of associates and physicians, and thedisplacement of order-processing systems generally favored by the clinicalcommunity.

Starting Small: Trinity Hospital’s Conversion. Because of its smaller andtherefore more manageable size, Trinity Hospital, a 263-bed community-basedhospital, was the first site converted to the Y2K compliant system in March1998. To its credit, Trinity quickly adapted and integrated the new processesinto its daily routine. The IS conversion team analyzed Trinity’s implementa-tion and documented suggested modifications for future conversions.

With any conversion, every effort is made to improve on the function-ality to be replaced. At the very minimum, the new system should maintainthe status quo. So was the case at Trinity. Physicians were not avid usersof the old order entry system, and the initial approach to physician instruc-tion was to demonstrate briefly the functionality in the physicians’ loungeduring implementation. The new system, however, meant a change in howphysicians acquired their in-house census listings. As a result, trainingrequirements burgeoned. At the end of Trinity’s implementation, moreresources for physician training were incorporated into the rollout plan forthe next site.

Next: Christ Hospital & Medical Center’s Conversion. One significantphysician concern at the next conversion site was remote access to the hospi-tal systems from physicians’ private practices. Advocate’s three largest hospitalfacilities—Christ Hospital & Medical Center, Good Samaritan Hospital, andLutheran General Hospital—offered physicians external access to patientorders and results. Each of these three sites used a different means to dial upand gain remote access to information. As physicians upgraded their officecomputer systems for the new millennium, all three hospitals were beginningto encounter problems with remote physician access.

Addressing Remote Physician Access. To address immediate concerns andavoid performing software installations at hundreds of physician offices, Advo-cate IS worked to make the new system accessible through the originalmodem-based remote access process. Simultaneously, the IS networking teamstarted to develop a more secure (HIPAA preparation) automated methodol-ogy for dial-up networking.

Physicians Feel Impact of Change. After five months of planning and prepa-rations, Christ Hospital & Medical Center was converted to the newpatient accounting and order entry system in September 1998. Unlike Trinity,the 792-bed trauma center and teaching facility had a physician communitymore accustomed to using their existing computer systems to check on the sta-tus of orders and results. Although more training was available, the impact ofthe conversion on physician processes was not fully understood or communi-cated. As a result, active physician attendance at scheduled training sessionswas far less than predicted.

Shortly after conversion, it became apparent that the new system was notmeeting the physicians’ needs. Site leadership received complaints that the newcompliant software was awkward to navigate, not intuitive to the patient careprocess, and as a menu-driven system considered a step back technicallyamong today’s graphical user interface (GUI) offerings. Many physicians sim-ply refused to use it. Even worse, several vocal physicians requested that theold systems be immediately restored.

Advocate Listens and Responds

In response to these issues, Christ Hospital facilitated feedback sessions withIS to address physician concerns. IS determined that the newly installed appli-cation could not be reasonably modified to accommodate the physicians’ sug-gestions. Therefore, during the continuing flurry of Y2K preparations, IS choseto develop a compliant solution to meet Advocate’s physicians’ definition of aclinical information system.

Product Definition. An information systems leadership team (ISLT) usedphysician feedback to define the product as follows:

• Maintenance of patient-centric view of data available in the current system• Long-term data storage capability• Web-enabled system for ease of use, adaptability, and minimal end-user

training requirements• Robust enough system to support future growth, including a plan to

incorporate a master patient index• Advocate-owned and -operated system

To get a solution implemented as soon as possible, the ISLT limited thescope of development to the data available to physicians from the current sys-tem. Wanting to avoid the “just one more feature before release” syndrome and

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the tendency for sites to personalize applications, the ISLT required that thenew application address only the physicians’ most immediate needs. Hospitalcensus, patient billing data, radiology reports, and lab results were set as themost pressing priorities for phase one development and initial applicationdeployment.

Assessing Patient History. As is their purpose, patient accounting systemscollect, display, and process data by patient encounter. This approach conflictswith how clinicians care for their patients—that is, viewing the entire patienthistory rather than just one isolated episode or encounter. The Advocate physi-cians requested a system that would allow them to identify a patient and viewtheir results across the continuum of care, regardless of visit type. Using min-imal navigation, they wanted to “select” a patient once and see all available datafrom any inpatient, outpatient, or emergency department visit.

Similarly, the physicians wanted to see as much historical patient data aspossible in order to identify trends and evaluate clinical indicators. To accom-modate accurate billing, the Advocate patient accounting system receives andrecords patient results. However, results are purged after ninety days to main-tain system performance. To facilitate a chronological view of a patient, theISLT required any new system to hold data in a primary database for two yearsand simultaneously populate a separate historical database to maintain infor-mation indefinitely.

Browser Flexibility. Advocate wanted to capitalize on the power and flex-ibility currently available from browser technologies. Because of time con-straints and post-Stark legal considerations, IS needed to avoid visitingdesktops—internal and external—to facilitate use of the proposed application.Web-enabling the new product allowed Advocate to offer access with minimalstaff intervention for training and installation. Browser access provides anattractive display (GUI) with point-and-click access to data while minimizingcosts and end-user requirements.

The proposed application had to be accessible from any Advocate desk-top running Windows 95, Windows 98, or Windows NT along with a system-approved browser (Internet Explorer 4.0� or Netscape Navigator 4.0�).Off-site access required the same workstation configuration, plus a modem todial-in to Advocate’s network and a CD-ROM drive to load the remote networkaccess (RNA) program developed by the IS networking team.

Remote Access. Remote access eliminated the need for the Advocate ISstaff to visit external desktops. Previously, hospital sites minimized liability byonly facilitating access from the physicians’ public offices; however, RNA meantphysicians could initiate access themselves from locations most logical tothem—even from home. Networking also incorporated more comprehensivesecurity into the RNA project. Users complete a confidentiality agreement andare assigned passwords per the Orange Book standard.1 By providing secureaccess to Advocate’s network, the new application could house patient datasafely inside the Advocate firewall.

Just the Beginning. In addition to addressing immediate needs, both theISLT and the physicians wanted a system that could grow to become a com-prehensive physician resource incorporating functions such as medical records,library links, order entry, and more. Advocate also wanted to leverage its posi-tion as a health system by preparing the new system to trend results not onlyacross multiple site-specific episodes but also across Advocate’s multifacilitycontinuum of care. Although many physicians are on staff at several Advocatesites, patient crossover between facilities is still relatively minimal. However,patient referral patterns between Advocate facilities are starting to emerge thatwill require any new system to take this important trend into consideration.

In the months following the Christ Hospital conversion, the ISLTresearched market options ranging from vendor-implemented solutions,consultant-facilitated processes, and front-end add-ons. Because of expectedcosts, physician-relation sensitivities, and extremely tight time frames,Advocate chose to develop a solution internally rather than seek an off-the-shelf product. Internal development provided the control to adapt the appli-cation to physicians’ specific needs quickly, and this in turn fostered acooperative relationship.

Advocate’s Product Emerges

The ISLT formed a team of information systems staff associates and technicalconsultants to facilitate project management and programming. The projectofficially kicked off in May 1999. Three key sites were targeted for develop-ment and pilot: Christ Hospital & Medical Center, Good Samaritan Hospital,and Lutheran General Hospital. Throughout the summer, the team workedwith physicians at the sites to design the front-end user interface and screenlayouts. At the same time, IS worked to develop the back-end database pro-gramming and processing functionality. By fall, the application was ready topilot.

Technical Overview. The results viewer application has three main com-ponents: a parsing engine, site-specific databases, and a browser front-end. (SeeFigure 1.) Communication among components is handled with HL-7 messag-ing and SQL queries. Although systemwide patient results are planned for thefuture, patient data are stored by site. The database structure is designed even-tually to accommodate a master patient index, but for now maintaining datain separate databases maximizes system performance. To provide high perfor-mance as well as long-term data availability, data are stored in both a produc-tion and a historical database for each site.

Standardization of the core information system applications greatlyreduced the application’s development time. An interface engine directs datafeeds from the Advocate standard patient accounting, order entry, laboratory,and radiology systems directly to the parsing engine. The parsing enginethen analyzes the data and prepares them for database population. The IS

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integration team created data threads for each database to accommodate ADT(admission-discharge-transfer) information, orders, and results. The parsingengine resides on a Windows NT server running the two services—productionand historical—for each hospital site.

The production and historical databases reside on two UNIX servers. Datatransfer from the parsing engine through a set of stored procedures before pop-ulating the database. A set of business rules directs how patient information isnormalized and which data serve as key fields (such as medical record num-ber used as a patient identifier). In addition to daily backups, IS performsbiweekly database consistency checks to verify integrity and assure accuratedata processing. In the case of unexpected production server downtime, front-end queries are redirected to the historical database server. This process pro-vides a level of redundancy and high-system availability not normallyobtainable in a production environment.

Also on a UNIX server, the Web front end combines C��, Java, Apache,and other tools to create the graphical user interface and query capabilities. Anaddress was added to Advocate’s domain name server (DNS) and is password-

Figure 1. System Infrastructure

Physician/office

Transaction server

Interface engine

1. Interface via TCP/IP2. Parse HL-7 messages3. Populate the database

HL-7 messages

Web server

Physician/office

Physician/home

Registration &order entry

Physician/home

AHCIntranet

Dial-upnetwork

Legacycloud

SAMLutheran Christ

Lab

Radiology

accessible through the Advocate Health Care intranet. The single browser-basedfront end serves all sites with log-on IDs directing access to the correct database.

Physician Direction. The first step in the front-end development processwas to establish a forum for ongoing physician input. The development of theresults viewer became a logical agenda item for Lutheran General’s PhysicianInformatics Committee, which met monthly to discuss clinical technologies.To facilitate product development, Good Samaritan chartered a similar infor-matics team and Christ Hospital convened an ad hoc physician committeeculled from its care management team.

The development team routinely met with physicians to discuss systemrequirements, set developmental direction, and request feedback. IS site leadsmanaged the meeting agendas, which generally included a development sta-tus report, a demonstration of current and planned functionality, and anopportunity to identify future growth. Physician guidance ranged from globalfeedback, such as what results to target for future releases, to participation ina survey specifying which data fields to include in the census header.

Overall, physicians affirmed the initial project scope that IS had identifiedand significantly influenced design for the four initial functions: census, billinginformation, orders, and results. Physicians were also instrumental in thedesign and function of the navigation toolbar. This easy-to-use toolbar was cre-ated to facilitate access to all functions with a quick click of a button. (See Fig-ure 2.)

Release 1.0

Release 1.0 includes the following functions.Census. Upon log-on, the results viewer displays the physician’s in-house

census (any patient assigned to a bed). Physicians can set their preference foreither their individual or their group’s census, and they may change the census

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Figure 2. Overview of the Main Toolbar

Log-off

Medical reference links

Status display area

User profilePassword

Link to help section

Search for patients

Go to your custom patient list

Go to your default patient list

Select your patient census

Select your patient summary

Patient face sheet

Patient visit history

View lab and radiology orders

View lab and radiology results

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display at any time by selecting an option from the census drop-down box.Other census choices include outpatient and emergency visits as well as theability to note recently discharged inpatients. Through the user profile (seeFigure 3), physicians can set preferences such as automatically sorting the cen-sus by patient name or by unit.

Another censuslike feature allows users to create a customized patient list.The custom patient list tracks patients regardless of visit status or recordedcaregivers. It is particularly useful for residents, who are not tracked as physi-cians of record but need to complete patient rounds. The system also offerscomprehensive patient search tools to identify patients by their demographicinformation, visit history, or documented physician–physician groups.

Billing Information. The system maintains a complete history of patientdemographic information, including the ability to track insurance datapertaining to each hospital visit. Physicians can view a summary of a patient’svisit history, noting dates of service, type of stay, and attending physician.The visit history screen offers links to the visit-specific face sheet that containsan overview of patient demographics and episode data, including up to ninecaptured insurance profiles and all physicians of record. The most recent facesheet is accessible from the visit history screen, or by clicking the face sheetbutton directly.

Figure 3. User Profile

Orders and Results. The system maintains the order and results historyfor all patient laboratory and radiology orders. Physicians can review a com-plete order history or limit searches to a twenty-four-hour, seventy-two-hour,or seven-day summary. The order summary screen displays the ordering physi-cian and order status, noting when specimens are received in the lab or if anorder has been canceled.

Results can be accessed from the order screen or obtained directly fromthe results drop-down box. Radiology and laboratory results can be viewed;in addition, labs may be trended or graphed. Physicians can narrow the scopeof the results view by selecting specific subdepartment data (that is, microbi-ology, chemistry, and so on for lab; mammography, X ray, and so on for radi-ology) or by limiting the date range. The results view provides a headeroutlining test-specific data and includes a patient phone number for ready ref-erence. The system highlights any abnormal values in red and provides linksto a trending function directly from the results viewer screen. Graphing capa-bilities support a visual reference of up to four components. (See Figure 4.)

Security. The system features related to security include user registration,self-assigned passwords, audit trail reporting, disabled cache, and an automatictime-out for inactivity. Upon initial log-on, every user completes the registrationscreen, agreeing to the Advocate confidentiality policy and providing personalinformation, including mother’s maiden name, last four digits of social securitynumber, and birth date. This personal information, stored in the database, facil-itates a self-assigned password process. Physicians can identify themselves to theapplication and reassign a new password rather than call the IS help desk.

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Figure 4. Graphed Lab Results

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System administrators can access audit trail reporting. Weekly usage sta-tistics are provided to the site leaders, notifying them of who is using the sys-tem. Similarly, administrators can run audit reports tracking the data by bothuser and patient. Disabling cache prevents unauthorized users from “backinginto” the application from an abandoned session. Similarly, physician users areautomatically logged off after five minutes of inactivity.

Pilot and Initial Rollout. A fifty-member informatics team piloted version1.0 in October 1999. Throughout the month, physicians reported issuesdirectly to CareNet site leaders, who coordinated resolution with developmentstaff and IS staff as appropriate. At the end of the pilot, physicians participatedin feedback sessions hosted at their respective hospitals. The physicians maderecommendations for improvement and brainstormed ideas for future func-tionality. At the conclusion of the meetings, each site physician team approvedopening access to the general physician population.

The November 1999 general release of version 1.1 included one extra fea-ture: access to Advocate’s health sciences library was added to the home pageand navigator bar. The library provides physicians with direct access to theelectronic version of Harrison’s Textbook of Medicine, CancerNet, and the Na-tional Library of Medicine. Planned enhancements for 2000 include Web-enabling the main library system and providing access to MDConsult.

By December 1999, over four hundred physicians logged on to the sys-tem. Utilization is mostly attributed to word of mouth among physicians,although IS staff provided demonstrations and training in the physicianlounges in early November. Ongoing meetings with the physician informaticscommittees continue to provide direction for future development.

Plans for the Future

Envisioning a tool to access patient information from any point along the con-tinuum of care, Advocate anticipates greater challenges as the system is pro-moted to other sites and other clinical communities. Critical to ongoing successwill be the continued standardization of core applications. The system’s rapiddeployment relied heavily on the consistency of data feeds from the patientaccounting, order entry, laboratory, and radiology applications.

New Sites. The system will be released to the five remaining hospitalsites throughout 2000. The three hospitals currently operating on Advocate’sstandard core systems (Bethany Hospital, Good Shepherd Hospital, andTrinity Hospital) came on-line in January 2000. The two remaininghospitals, Ravenswood Hospital & Medical Center and South SuburbanHospital, are not yet converted to the Advocate standard patient account-ing system because their current systems were Y2K compliant. The resultsviewer will be implemented in conjunction with their respective patientaccounting system conversions: South Suburban in June, Ravenswood inOctober.

Coordinating access to patient data throughout the health system will bea challenge in 2000 as the results viewer reaches out to serve other sites, suchas home health and outpatient diagnostic centers. As referral patterns movetoward keeping patients in the health system, the system will need to addresshow best to accommodate access to multiple databases while maintaining sys-tem performance.

Nonphysician Users. Besides expanding to more sites, the results viewer isdrawing the attention of other clinicians, such as nursing and allied health pro-fessionals. As the system continues to simplify access to more clinical patient data,more Advocate associates will prefer to use it over more cumbersome processes—especially manual ones! IS may need to form auxiliary projects to address the spe-cific data needs of each group of users to best serve all potential customers.

Enhancements. IS intends to keep the results viewer focused on address-ing physician concerns. Features and functions planned for 2000 includeanatomical pathology, discharge summary completion, medical record tran-scription, electronic signature, automated results notification, referral pro-cessing, and electronic mail.

Partnering with Health Information Management. Completing thepatient medical record remains the one cumbersome administrative task forphysicians. The development team is working with medical records managersto facilitate completion of the discharge summary report. The system will dis-play the most recent orders and results, provide a template allowing physiciansto complete and sign the form on-line, and route the document to health infor-mation management departments for chart completion. By presenting theavailable results, the development team hopes to effectively reduce the time aphysician spends in gathering the appropriate data to complete the report.

Similarly, medical records dictation encompasses the bulk of the patientmedical record. Information systems is working with the primary transcrip-tion vendors to route data to the results viewer in hopes of displaying reportsas early as this summer. Once on-line, the system can facilitate electronic sig-nature for dictated reports.

Striving for Push Me–Pull Me. Advocate acknowledges two critical physi-cian reporting needs: to provide physicians the ability to look up patient resultsinformation (pull), and to notify physicians that results are available for theirpatients (push). Thus, the development team plans to transition from a sim-ple inquiry-based tool to encompass results-notification functions. To accom-plish this objective, personalized physician Web pages and e-mail notice areunder consideration. The system is also targeted to transport other physician-related communications, such as referrals.

Looking further into the future, physician informatics teams are requestingthat the system facilitate order entry and other data input functions. Advocateanticipates that making electronic orders available can improve patient care byreducing transcription errors, alerting duplicate orders, and noting formularydiscrepancies.

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Standardization of Clinical Systems. As more information systemsstandardize at Advocate, more patient data will be available. Although labinformation systems are consistent throughout Advocate, many other coreclinical applications are yet to be standardized. Rather than create interfacesfor eight or more systems, Advocate is focusing on consolidation to simplifydata transfer; and system users will continue to benefit from standardiza-tion. For example, results from Advocate’s systemwide pathology systembecame available in February 2000. To facilitate interfacing eight feederinformation systems would have lengthened development by two monthsor more. Furthermore, Advocate is in the process of identifying systemwideapplications for radiology, pharmacy, and emergency department systems.The development team is targeting integration with all of them.

Keys to Success

The physician-driven results viewer changed the IS leadership’s approach totechnical projects.

Partnership with End Users. The advantages of including the end user atthe very beginning of the project became evident at rollout as physicians vol-unteered for committee participation, displayed pride of ownership, and fos-tered goodwill with IS associates.

The physician informatics teams continue to pull strong attendance. Stan-dard agenda items include discussion of the results viewer and other clinicaltechnologies as well as more political issues, such as how to balance clinicianaccess with patient confidentiality.

The original pilot physicians requested that their names be published sotheir colleagues could approach them directly with questions about the systemrather than seek out IS associates. When new features are announced, physi-cians vie for bragging rights to the original recommendation for improvement.

Most important to IS, however, are the positive remarks users are sharingwith the development team and management. Physicians continue to expresstheir appreciation to IS staff for listening and responding to their request for apatient-centric, easy-to-navigate clinical results viewer.

Full Circle of Patient Data. Today, the results viewer serves as a founda-tion of patient information gathered during the acute care hospital visit. ISleadership envisions it growing to accommodate patient data populated out-side of Advocate—from the physician practice, and even from the patientsthemselves. An IS team is exploring options that could combine physicianpractice updates with hospital information to a patient-specific Web page.Patients could access their own password-protected Web page to update theirmedical history, insurance information, and other personal data. The goal ofthis collaborative effort would be improved patient histories, up-to-date clin-ical information available to all providers, and better health decisions made byclinicians and patients.

Partnering with physicians allowed IS to develop and deploy the systemrapidly. With continued physician collaboration, aggressive product updates,and a systemwide focus, the results viewer will continue to be an essential andprominent physician resource. By partnering with patients, the system can real-ize the true benefit of a centralized results repository: a healthier community.

Reference

1. Department of Defense Trusted Computer System Evaluation Criteria (commonly referred to asThe Orange Book). Department of Defense Standard. DoD 5200.28-STD.[http://www.us.kernel.org/pub/linux/libs/security/Orange Linux/refs/Orange/Orange0.html#toc1]

About the Authors

Janice A. Wurz, leader of the results viewer project, joined Advocate Health Care inJuly 1997. She has worked with physician information systems for nearly ten years,focusing on communication and clinical reporting.

Jonathan L. Manis, MIS, MBA, Director, Application Products and Projects, and a mem-ber of the ISLT, joined Advocate Health Care in December 1996. A graduate of the U.S.Naval Academy Postgraduate School, he holds master’s degrees in information systemsand business administration.

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