Volume 16, No. 1, February 2006
Integrated Information System for the
Heart Institute, São Paulo
Divya Tewari
Centre for e-Governance, Indian Institute of Management, Ahmedabad
[This article has been prepared on the basis of the information provided by Marco Antonio Gutierrez, Technical Director of Computer Services, Instituto do Coração do Hospital das Clínicas, São Paulo, Brazil. The project details were submitted to a UN agency that was selecting projects for awards.]
Abstract
The Heart Institute (InCor) of São Paulo Medical School has successfully created a system called InCor Integrated Information System, or I3S, that comprises both patient health information and institution’s administrative and clinical information. The System acts as a new technological alternative to the paper records. The system was designed in modules that permits patient admission, discharge and transfer (ADT), registration of medical activities, registration of diagnoses and therapy, order entry and access to all patient data, including vital signals, images and lab tests. The modules are integrated in a single Web-based application allowing an easy and fast navigation through the modules.
Application Context
The
Heart Institute is one of the six Institutes of the University of São Paulo
Medical School Hospital and one of the most active cardiac centers in the
world and a reference center for this field in
Traditionally,
clinicians have been working with paper reports and exam films that result in
problems for storage, organization, and slow access to stored information and
reliability. The goal of the Electronic Health Record (EHR) is to present all
information from a patient to the health professional. The information could
even be from different systems or hospitals. In order to be able to build such
a complex system it was necessary to integrate several fields of Information
Technology, such as:
-
Use of international models and standards in terms of hardware, classification, medical vocabulary, as databases, biological signs and medical images.
-
Integrate information from image exams to the Hospital Information System;
-
Increase the network infrastructure to allow faster information exchange inside the Institution and among Institutions;
-
Research and development of contextual image viewers.
A New Approach
The
initial modules comprising patient admission, emergency admission and bed
occupation were delivered to the Hospital routine in 2003 November. A key
point in the development was the modeling of patient data, including medical
images as part of the global patient information. An object-oriented
representation of the whole clinical image domain and its integration to the
Hospital Information System (HIS)
was developed. Representation of images is based on DICOM3 (Digital Imaging
and Communications in Medicine) standard for communication and storage of
medical images. This standard incorporates associated data such as
identification of the patient, performed study, image acquisition context and
image interpretation findings. DICOM3 standard describes a patient-oriented
model that is well suited to follow all information related to a patient.
However, as the main purpose of the project is to allow a higher level of
complexity in searches, the model proposed on the standard was expanded in
order to fulfill the requirement of retrieving medical images from any
attribute. The new model allows the representation of different image
modalities, integration of these modalities in the same study, investigation
of similar images from different patients and contextual visualization and
processing of clinical images. Another important issue is that Electronic
Patient Record (EPR) is constantly evolving, therefore the architecture should
be flexible enough to accommodate new functionality and technologies. The
implementation was based on client-server architecture via Web servers
connected to several databases and subsystems: HIS, image database, document
database, signal monitors and Resource Access Decision (RAD) subsystem.
Infrastructure: the
network model at InCor is composed of a heterogeneous platform, which allows
scalability and uses Fast and Gigabit Ethernet technologies. The protocol is
TCP/IP. The client network stations use Fast Ethernet, and the backbone has
capacity to operate on Gigabit Ethernet. For exchanging information on a long
distance term, protocol ATM was used. InCor was one of the Institutions to
participate in a National project that intended to create metropolitan
high-speed networks.
Hospital Information System structure:
The structured information of HIS at InCor is formed from several clinical
information sub-systems: lab exams; clinical reports; hospital procedures;
diagnoses; prescriptions; patient evolutions; dismissals, etc.
Medical Image Data: Picture Archiving and Communications System (PACS), is based on the international standard for medical images DICOM3. The system comprises a DICOM Server that receives the images from the imaging equipment, stores them and updates the information concerning those images in HIS database. An automatic storage management system is responsible for data security and redundancy. For the visualization of images, a DICOM viewer was implemented that allows the manipulation of static and dynamic images.
Scanned Document data:
Some important patient information is still in paper format, such as the
patient’s consent. Since the EPR should provide all relevant content, it was
decided to include this kind of data as scanned documents.
Real-Time Signals data:
Real-time vital signals, such as Electrocardiogram (EKG) and respiration, of
patients in surgery and intensive care are obtained via special patient
monitors that are able to communicate with other computerized systems via HL7
protocol (Health Level Seven). All communication between the network of
monitors and the hospital network is carried out through an implemented HL7
server that integrates this type of data with the HIS.
Access Control:
Designing proper models for authorization and control of access is essential
to wide scale use of the EPR in large health organizations. To ensure this, a
contextual role-based access control (RBAC) authorization model has been
implemented. The implemented RBAC regulates user’s access to system
resources based on organizational roles. A contextual authorization uses
environmental information available at access time, like user/patient
relationship, in order to decide whether a user should be allowed to access an
EPR resource.
Web
based:
the system implemented is web based and can be accessed from Internet point by
an authorized user, clinical or administrative.
Implementation
Challenges
Although
InCor had electronic systems since the 1980’s, many of these systems were
not integrated, and implementing the EPR was a challenging goal envisioned by
the group. For modeling, implementing and delivering such an integrated and
comprehensive system, changes were required in work processes, redrawing many
hospital processes and patient workflow. To perform this task a close
interaction was required with all the areas of the hospital, to obtain their
understanding, agreement and cooperation. To achieve this cooperation, an
important issue was to show that the success of the results would overcome the
possible disturbance during the process of change. An example was the change
in the Admission, Discharge and Transfer (ADT) process
The legacy
systems were partially electronic and partially manual. Besides, they were
operated in a centralized way. In the new approach, ADT tasks are performed
and distributed by physicians, nursing, administrative and maintenance staff,
optimizing the process and thus reducing time and cost.
Creating
an electronic counterpart of the traditional paper records, concerning both
clinical and administrative information from the patients was not easy. The
development of I3S involved many technological and methodological
challenges, from the upgrade of the network infrastructure to the development
of client applications. The greatest problems were:
-
the huge amount of data to be manipulated;
-
many physicians were unwilling to trade the ease of writing paperbound annotations for a system that requires them to type the same information into a computer;
-
legacy equipment that do not have capacity for digital communication;
-
inadequacy of network infrastructure;
-
legal aspects;
-
lack of a general model in the field of medical information.
Benefits and Costs
The
potential advantages of an EPR over a traditional paper-based patient record
involve distributed and simultaneous access, high availability, fast
information retrieval, better quality and higher confidence. The routine use
of electronic records could help reduce a great number of deaths and injuries
caused by medical mistakes that can be the result of delayed or low quality
information.
Incor´s
network has more than 1000 access points, from which the system can be
accessed. Network clients are conventional PC´s running MSWindows or
thin-clients running Linux. The number of daily access to the I3S
is about 1400. The number of patients in the InCor´s database is about
880,000. The large number of patient admissions, medical appointments,
surgeries, prescriptions, angiography etc. employing I3S, speaks of
its success. The system also allowed a better management of the Hospital
Resources: material, bed occupation and procedure costs.
A great part of the financial resources came from grants from Brazilian Research Foundations. Part of the team involved in this project was also sponsored by grants from these Foundations. The rest of the resources and team comprised the staff of the IT group from InCor.
Key Lessons
The
experience in implementing this system showed that designing a good model for
the workflow along with a good program of training, allied to the user
involvement in all phases of the project is the best strategy to convince the
clinicians about the importance of using the EPR. I3S has been
instrumental in changing the old culture among the clinicians. Having used the
system, they realize that in the long run the electronic record can make
hospitals more efficient, reduce medical errors and lower health-care costs.
One can consider that such a sophisticated environment would be useful only for countries or regions where the basic health problems have been already solved. However, this is a misconception. The increase in efficiency due to the use of electronic health systems in public hospitals of developing countries can, without decreasing the quality of service, eliminate duplicated treatment, shorten hospital stays and get patients out of unit care units faster. For public hospitals, the reduction of costs generated by these systems would allow the increase in investments toward the population by increasing the availability and the quality of health services.