First UP
SOA-Based Electronic Medical Records System Improves Quality of Cancer Care
The University of Texas M. D. Anderson Cancer Center—one of the world’s largest cancer
centers—has a mission: to eliminate cancer. Each day, the professionals at M. D. Anderson work
diligently toward achieving this mission by providing high-quality care based on the latest
cancer research. However, it’s not just talent and in-house clinical expertise that enable their success.
Timely access to relevant patient data helps practitioners make appropriate clinical decisions
that are in the best interest of their patients.
Safely and securely providing patient data to cancer care practitioners when they need
it is an enormous challenge. Not only does it require determining how to share massive amounts
of disparate data—from radiographs, to lab tests, treatment regimens, and research protocols—from
a variety of systems, but it also requires integrating inpatient, outpatient, and research
information into a complete and logical electronic medical record (EMR) while ensuring the
privacy rights of every patient. Sound difficult? Perhaps, but these requirements did not daunt
the IT staff at M. D. Anderson Cancer Center. After all, this vision was the next step to
evolving an application developed in-house.
The beginnings of EMR and SOA
ClinicStation (v 1.0), created in 1999 by M. D. Anderson IT professionals, integrated
the presentation of radiology images with clinical data from a variety of IT systems.
Not only was this solution an early move towards an EMR that helped to reduce paperwork
and improve information flow, it was also a step toward a service-oriented architecture (SOA),
even before SOA was introduced on a wide-scale basis. That is, M. D. Anderson IT staff designed
ClinicStation to use services that work together as components to integrate the radiology images
with the clinical data. ClinicStation was a great success in its support of improved patient
care and as a result, new features were added over the next few years and it evolved
into a complex workflow system.
For all the success and adaptability of ClinicStation v 1.0, the base architecture
and technologies (Microsoft Visual Basic 6.0 and Component Object Model (COM)) could
not support the features and functionality for a complete EMR system. Therefore, when
it was time to create a complete EMR, M. D. Anderson first sought to adapt commercial EMR
products to suit their needs because they knew that home-grown applications can be difficult
to support. This turned out to be more challenging than anticipated. For one, most commercial
EMR products are made to track acute health care services in an inpatient or outpatient setting.
M. D. Anderson, unlike most health care facilities, not only provides inpatient and outpatient
services, they closely integrate their clinical practice with their research studies. Because
so few institutions have such a tightly integrated approach to health care, let alone cancer care,
few products came close to meeting their requirements.
Choosing the right partner and the right platform
Despite massive efforts to adapt off-the-shelf products to support their vision, M. D.
Anderson decided to build their EMR solution in house. "Our vision for the EMR is a
virtual clinical repository with the flexibility to add new systems and data sources
extremely easily," said Lynn Vogel, MD—Vice President and Chief Information Officer
for M. D. Anderson. "And by using a services oriented architecture framework, we don’t need
to go through the complicated process of moving data from system to system."
"In terms of IT," added Chuck Suitor—Director, EMR Development and Support, "we wanted to
make sure the architecture would support us for a long time to come. We needed an infrastructure
that could guarantee performance, scalability, and reliability."
However, with a small staff of developers and an aggressive, nine-month delivery schedule,
they needed help. M. D. Anderson sought Avanade as their partner for a variety of reasons.
First, because cancer care cannot wait for a delay of a software release, M. D. Anderson needed
access to a cadre of highly-skilled professionals to help them build their solution on their
aggressive timeline. Second, M. D. Anderson knew that Avanade has proven experience in helping
clients to build and manage large-scale development teams and staff, expertise and tools,
such as ACA .NET, to facilitate knowledge transfer and help current staff retool from Visual
Basic to C#. Finally, M. D. Anderson needed additional expertise and they found that Avanade
had unparalleled expertise in mission-critical .NET/SOA development.
Because M. D. Anderson wanted an EMR built on a service-oriented architecture using a set
of technologies that could support their existing heterogeneous systems, Microsoft products
were a natural choice. Using the Microsoft .NET Framework as the basis for the SOA architecture,
the new version of ClinicStation integrates data from more than 40 systems. Microsoft SQL Server 2005,
SharePoint Portal Server 2003, Operations Manager 2005, and Web Service Enhancements for Microsoft .NET
version 3.0 are used to support information integration and patient privacy.
This approach supported individual department needs to use clinical software that meets their
specific needs while enabling M. D. Anderson to integrate inpatient, outpatient data, and clinical
research data into a patient’s electronic medical record, a first in the health care industry.
Further, this approach supports one of their IT principles: not to move data unless it is absolutely
necessary. Says Lynn Vogel, CIO, "every time you move data from one place to another, you have
a risk that you’ll lose the data or that once the data makes it to point B from point A,
it’s out of date at point A. The SOA framework simply eliminates those problems."
Improved support of high-quality care, patient privacy, and patient experience
The original ClinicStation had a very rich set of features, and the newly written version
had to ensure that every feature was as good or better than the original. The new ClinicStation
not only enables a practitioner to view data from any number of systems in a single location,
it protects the privacy of patients by limiting the type of information that a practitioner—such
as a doctor, nurse, or pharmacist—can access depending on their role. That is, each role has access
only to the information that they need for the type of care that they provide, thus helping to
balance high-quality care with the privacy rights of each patient.
Just as important, ClinicStation improves the care and experience of the patients who receive
treatment at the M. D. Anderson Cancer Center. Patient visits at M. D. Anderson are usually an
intensive 2-3 day series of appointments that include meeting with a variety of practitioners,
getting lab tests, and/or receiving treatments. "A few years ago, it was not uncommon to see
patients walking around the hospital pushing wheelchairs. Unfortunately the wheelchairs didn’t
have patients in them, they had medical records in them," noted Lynn Vogel, CIO. The information
gathered at each stage of a patient’s visit needs to be shared with each practitioner
that they see. If a practitioner does not have access to the data, either a care decision
is delayed or the decision is not based on all the relevant data. Because the data accumulated
throughout a patient’s visit is immediately available to all practitioners, patients are
able to get the care that they need.
Additionally, the system can flow more efficiently because health care providers do not need
to be in the same physical location to share and discuss information. If two physicians need to
decide on a course of treatment, they can review a patient’s record at the same time and
collaborate on a course of action without being in the same location. And now practitioners can
collaborate in ways they could not previously. For example, Lynn Vogel relates a recent example
where an M. D. Anderson patient was in London and possibly needed additional cancer care:
"A physician was called on a Sunday morning because one of his patients had been hospitalized
in London. The physician calling him wasn’t sure what had been done at M. D. Anderson. Our physician
got on the computer, looked up the x-rays and the films, and then shared those films with the
physician in London so that they could have a joint consultation about the patient. It turned out
that there was no serious complication and the patient was discharged. If the physician in London
didn’t have that information, then they might have performed unnecessary procedures on the patient."
"We knew the institution would be counting on the features of ClinicStation, so performance
and functionality were key areas of emphasis," says Suitor. "The new version has exceeded our expectations."
Looking ahead
The new version of ClinicStation has enabled the M. D. Cancer Center to take patient care to
the next level of excellence. And, as an organization that continually strives to improve,
M. D. Anderson also knows that this is not the final solution. Cancer care, like technology,
is constantly changing and so ClinicStation must evolve. With a new, scalable SOA-based foundation
and a retooled and larger development team, M. D. Anderson will be able to expand, adapt, and continue
to improve ClinicStation and other IT solutions to help the cancer care practitioners move one step closer
to their mission of eliminating cancer.