PatientWebTM

A Case Study of Information Technology Success in Health Care

Copyright Megan Burns, 1999


Lowell General Hospital (LGH) is a 208 bed medical facility located in located in Lowell, Massachusetts.  In fiscal year 1995, its 1005 medical and nursing staff members discharged 11,724 patients, handled 140,101 outpatient visits, performed 15,953 surgical procedures, and ordered 1,124,685 laboratory tests [1].  In order to provide medical care to all of those patients, the staff of Lowell General uses a number of different resources, including medications, tests, equipment, and personnel.  Perhaps the most valuable resource it employs, however, is information.  Each patient visit generates a volume of new information that is accessed by doctors, nurses, insurance companies, and other hospital staff members to make decisions about the best course of treatment for that patient.  Managing such a tremendous amount of information is no easy task, and hospitals all over the country, including Lowell General, are looking for ways to improve the effectiveness and efficiency of their information management practices.  Several years ago, under the guidance of Chief Information Officer Edward Bianco, LGH began to investigate new and innovative ways to approach the task of clinical information management.  The following case study will show how Bianco has helped to turn LGH's information management system from a tangled mess of legacy systems into a cutting edge, cost-effective patient care resource.  We will look at the original technology in place at LGH, the new technologies put into place as a result of Bianco's effort, and both the benefits and the drawbacks of the new technology.

The Initial Hodgepodge

When CIO Edward Bianco began looking at ways to improve information management at Lowell General Hospital, he did not have much to start with.  "For a long time, Lowell General's network was a hodgepodge of NetWare, UNIX, and VAX-based LANs." [2]  He realized that it was time for a change because many of the technologies they were using were older, legacy products that were loosing support in both the user and vendor communities.  What Bianco did, then, was enlist the help of the information systems staff at Lowell General to prepare the hospital for the IT demands of the twenty-first century.  Not only did they "streamline the network and integrate old applications" [2], they also created a new application called PatientWeb that has perhaps been the most successful part of the entire re-engineering effort.

LGH's Solution - Untangling the Web

Figure 1, taken from the homepage of Lowell Technologies, Inc., the group responsible for creating the system at Lowell General,  shows the new information systems architecture put in place.  It is centered around a Microsoft Windows NT network and a secure intranet, using a thin client Intranet application called PatientWebTM to access clinical information used by doctors, nurses and other hospital personnel.
 


securweb3.gif (41547 bytes)

      Figure 1: Architecture of the Lowell General System

As you can see, the network is fairly complex.  This complexity arises from the number of difficult problems that must be handled when using Intranet technology to access health care information.  In fact, Lowell General's solution has proven quite successful in its ability to deal with traditional obstacles such as security, accuracy, and legacy information.

Security

With regard to the problem of security, PatientWeb has a number of solutions in place.  According to Lowell Technologies, Inc., the system uses up to 128 bit encryption across the network, passwords, tokens, digital certificates, multi-layer firewalls, and a role based access engine to help enforce information access on a need-to-know basis.  An article highlighting PatientWebTM in ComputerWorld magazine also notes several of the system's more innovative security mechanisms, including:

Accuracy

Because the information stored in hospital computer systems is used to make life-and-death decisions, it's essential that it be accurate.   The LGH network has several mechanisms in place to insure that the information available to medical personnel is as accurate as possible.  First, "[t]he network accesses the database in real-time, so the patient's file always accurately reflects the patient's status," [2].  Second, it allows physicians to order tests and enter new information online, and, of course, "putting all this information online makes it easier to keep current and accurate," [2].  In general, the system provides a single point of contact for information and uses technology to help monitor the consistency and correctness of information, all of which help maintain the most accurate reflection of reality possible.

Legacy Information

A third problem facing health care providers trying to modernize their IT infrastructure is the presence of old legacy systems housing vital clinical information.  The infrastructure created by Ed Bianco and his staff at Lowell General provides a solution to this problem that allows users to take advantage of the wealth of legacy information without a long and costly software integration effort.  "PatientWeb does not replicate existing medical information.  Instead, it serves as a conduit between the user and the legacy system" [3].  The LGH intranet is also home to "web-based terminal emulators," that "provide access to VAX and UNIX systems," [2].   By using the intranet as a central access mechanism, the LGH system puts a common face on information that is logically related, but that exists, for historical reasons, in different systems throughout the hospital.
 

Benefits of the LGH Solution

From the preceding discussion, it seems as though the new information management infrastructure at Lowell General Hospital provides innovative solutions to many of the difficult problems faced by health care information users.  It is currently in use by the staff of the hospital, and appears to be delivering on many of the benefits it promised. ComputerWorld magazine highlighted the system in an October 1998 article, quoting LGH staff doctor Navin Popat as saying "It cuts down on the time I have to spend waiting for paperwork and improves patient care."  The article also notes that Popat "can analyze information more easily because of PatientWeb's ability to produce cross-referenced data about a patient."

The Lowell General Hospital computer network was also named a 1997 NT Innovator by WindowsNT Magazine. According to the magazine, LGH was part of a group of "organizations that combined in-house development, third-party products, and of course, Windows NT to produce unique and innovative solutions to technical problems in the enterprise."  In particular, the magazine notes "[t]his innovative front-end for medical records makes obtaining and updating patient information much easier and more accurate than conventional record-keeping practices," and that "[n]urses and other users like the new NT system for another reason: ease of use.  Many users have worked on PCs before and were already familiar with the applications they were going to use, so they just needed to brush up on their skills."

In short, the LGH PatientWeb system and its supporting infrastructure have allowed hospital personnel to access information relevant to their jobs through a central, easy to use interface that maintains confidentiality of sensitive patient data while increasing its accuracy.  Project sponsor Ed Bianco sees the LGH system as "one of the most advanced clinical data repositories using Internet-based technology" [4]  and expects the number of users "to grow to at least 700 now that the system is fully installed and outside doctors are being invited to join". [5]

Concerns about the LGH Solution

Despite the many benefits provided by this new information management system, there are a few concerns that the author feels should be addressed by Ed Bianco and his staff in the near future.  These include the tight coupling between the LGH system and Microsoft Internet Explorer, and the system's dependence on legacy computer systems.

Microsoft Internet Explorer - Putting All Your Eggs in One Basket

Currently, PatientWeb and the system's other online interfaces require that the user be running Microsoft Internet Explorer (IE) as a browser.  By limiting users to a single Internet browser, designers have constrained their system in several ways.

First, they have tied its success to the success of IE so that, should IE become obsolete, the LGH system will have to be reworked or discarded due to its lack of compatibility with other browsers.  One of the primary benefits of the Internet, the ability to define content independent of the software that will render it, has not been taken advantage of because of the decision to use IE exclusively.

Second, they have forced some users to invest in a new technology.  Many Internet users already have a favorite browser, the most common of which is Netscape.  Although these users might not have to spend any additional money on IE because it comes bundled with most Microsoft operating systems, they will still have to invest time in learning how to use IE if they do not already.  This extra overhead might deter some hospital staff from using the system when it is not required (i.e. from home or outside the hospital itself), thus causing it to fail in achieving all of its intended benefits.

Dependence on Legacy Systems

In addition to its dependence on a single Internet browser, the LGH system is limited by its dependence on underlying legacy computer systems.  One current problem in many health care facilities, which LGH has addressed quite successfully,  is accessing information in these disparate systems in a timely, unified manner.  Another, perhaps more threatening problem, however, is how to support and expand these systems once vendor support begins to diminish.

With the LGH system, it may look to the end user as though the problem of multiple legacy systems has been solved.  In reality, however, IT support personnel still have to maintain and expand those systems that continue to house much of the hospital's essential information.  If vendor support begins to disappear for any of the products underneath the new network, the integrity of the entire system is compromised.   It will become increasingly difficult to insure the proper functioning of important pieces of the puzzle and, eventually, legacy systems will have to be replaced.  Porting legacy systems to new platforms is a tremendously costly endeavor, and LGH would be wise to start looking in that direction as the next step in improving its delivery of information to patient care providers.

Conclusions

Looking at the information management re-engineering effort at Lowell General Hospital, one can see a very successful application of  IT to the problem of delivering  health care services.  The current system has a few problems in its dependence on particular technologies, but overall, it takes great strides toward solving the most difficult problems in the industry.  By giving health care providers a single, consistent, convenient mechanism by which to access information about the patients they treat, PatientWeb and the LGH network are reducing the overhead associated with obtaining information required in the clinical setting.  This, in turn, improves the ability of medical personnel to make good treatment decisions, increases the level of care received by patients, and reduces the cost of providing the best care possible.  Few can argue that this is a winning situation for all parties involved, and hopefully other hospitals around the nation will begin to follow in LGH's footsteps.


PatientWeb is a trademark of Lowell Technologies, Inc., a subsidiary of Lowell General Corporation.

References

[1] Facts About Lowell General Hospital

[2] 1997 NT Innovators: Making a name with NT, WindowsNT Magazine, January 1998

[3] Lowell Technologies, Inc. PatientWebTM

[4] Memo to the Medical Staff of Lowell General Hospital from Edward T. Bianco, Chief Information Officer

[5] A Web fast track to patient files, ComputerWorld Magazine, October 1998.

This paper was written by Megan Burns for Information Technology and Social Accountability, a class in the Heinz School of Management and Public Policy at Carnegie Mellon University.