August, 1996 Image-enabling the healthcare enterprise By Fran Reynolds, Director, Product Management, LanVision The calll for healthcare providers today is clear: increase the quality and level of care while reducing costs. And yes, also, make sure you continue to expand your share of the market. As if this weren't enough, the entire industry is undergoing rapid and dramatic fundamental changes in the model of healthcare delivery as it deals with issues such as managed care and capitation. These forces are having a profound effect upon the way that healthcare organizations view their information technology today. It is clear that hospitals and healthcare systems that are able to provide an up-to-date patient record that contains all clinical and financial information across the entire enterprise will be well-positioned to meet these challenges. As the traditional medical record evolves into a combination of electronic data, multimedia medical images and paper-based information, the healthcare community is faced with many challenges in ensuring users have timely access to the total medical record. Contrary to the hopes of hospital CIOs, it is becoming universally accepted that paper-based information will more than likely be a permanent part of the patient record. Today, in fact, paper-based records continue to represent the vast majority of the record in most hospitals, and even the most optimistic projections show paper declining to no less than 20% of the record. Consequently, a comprehensive computerized patient record (CPR) must provide some way to scan and index the paper portion of the record. In this way, the paper-based information can be retrieved and processed as easily and quickly as the electronic portion of the record. The volume of medical images in the patient record is expanding dramatically, as well. In addition to classic images such as X-rays and CAT scans, new image forms such as digitized slides, videos and photographs proliferate. The ultimate CPR would incorporate all data which could be electronically stored and computer-accessible images of all paper-based data to form a patient record which would be completely retrievable and completely paperless across the entire enterprise. The advantages of a computerized patient record are compelling and generally well known: first, they consolidate all health information, whether text, images, sound, or video into one easily accessible repository. This provides instant access to the information from any computer workstation. This is in sharp contrast to the national average time to retrieve a typical patient record of over 45 minutes. Secondly, CPRs allow multiple people to access the same patient record simultaneously, completely eliminating file contention. This does away with one of the greatest drawbacks to the traditional paper record where only one person can access the record at a time. Thirdly, a CPR provides immediate access to documents which are required for billing, eliminating the need to route hard copies of these documents between hospital departments and third parties. This directly improves the hospital's cash flow by accelerating accounts receivable collections and reducing technical denials. Also, by computerizing the patient record, hospitals can virtually eliminate the problem of lost files and documents. Some hospitals have reported file loss rates of a startling 33% or more. Central data repositories and imaging The information management needs within a healthcare enterprise are enormous and the IS infrastructure comprises an assortment of applications. Typically, at the center are Health Information Systems (HIS), which are usually host-based and can include such systems as patient financials, electronic medical records (EMR), admitting and discharge and the like. In addition, there are numerous other departmental systems, such as enterprise-wide scheduling, lab and radiology. For the most part, all of these systems are standalone with little or no integration. While each application usually contains its own local database, hospitals generally employ a central data repository (CDR) where the collective data from all of these systems is stored and managed. This not only helps control the redundancy of common information across applications, it also provides a consistent format and organization for the data. For many, this is the closest they come to any sort of integration among disparate systems. And indeed, it is a major step in the direction of the CPR. However, these repositories are limited to structured electronic data, i.e., letters and numbers. They cannot, by themselves, handle unstructured data such as images, X-ray, sound and video. Looking for ways to achieve the vision of the completely computerized patient record, hospitals are turning to imaging systems in increasing numbers. This is due in part to such a system's ability to make paper-based information and unstructured medical images as readily available and easy to process as structured electronic data. However, unless the imaging system is tightly integrated with the central data repository, the dream of seamless universal access from a single workstation can't be achieved. A closer look at central data repositories The need to integrate imaging systems with the central data repository is best understood with a basic awareness of the attributes of these systems. CDRs normally incorporate three major components. First of all, their very function necessitates a massive database for storage of all electronic medical data. Secondly, to facilitate rapid access to the stored data by a variety of users--many of whom are non-technical--as well as to provide other capabilities such as printing and faxing, these systems require an advanced graphical user interface (GUI). Thirdly, they should contain robust interfaces to the many information systems in the enterprise so that they can collect the necessary data. Most of today's systems store this data exclusively on hard magnetic disk drives. As hundreds of gigabytes of electronic data pile up on system hard disks, there is a pressing need to archive this data to a less volatile, less expensive and more permanent media. At this point, typically an off-line archiving method is employed such as tape backup. Data that is archived in this manner, however, can take hours or days to retrieve. Document imaging systems provide the same basic functions as the CDR, except they can handle paper-based and certain other unstructured multimedia data. Like a CDR, imaging systems provide a database, GUI and interfaces to other systems. In addition, imaging systems also provide functions for scanning paper records at high speeds as well as automatically indexing them with bar codes. They can also store and retrieve the images and other data on optical storage media. Imaging systems normally use optical jukeboxes which hold dozens of optical platters that are loaded automatically into drives as required. A jukebox containing over a half terabyte of data can be as small as a two-drawer file cabinet and contain over 12 million pages of scanned images! Storing data on optical media provides numerous advantages over a paper record or an electronic record stored on hard disk (magnetic media). Optical discs cannot be modified after being written on, and can store gigabytes of data economically. In addition, they can provide a high degree of security. Storage considerations To put the efficiency of storage methods into relative perspective, on-line storage (such as data stored on a hard disk) is accessible in milliseconds. "Near-line" storage refers to computer records which are available in seconds, such as those stored on optical jukeboxes. Off-line storage (such as a paper record or tape) is retrievable in minutes, hours or days. Well-developed imaging systems can actually provide on-line performance with optically (near-line) stored data by using advanced caching methods that anticipate users' needs and copies needed files in advance to on-line hard disks. This allows the user of a high-performance imaging system to retrieve images of the paper record in a few seconds. An optical imaging system therefore provides cost-effective, permanent, unalterable, near-line storage of information. At the same time, it greatly reduces the physical space required for storing the vast amounts of information, which by itself can translate into a significant cost reduction. Integrating CDR with imaging With these facts in mind, many hospitals are looking to integrate their central data repositories with imaging systems. The advantages of this type of integration, also called "image-enabling," are many. For example, users can access any piece of information on the same workstation and from the same screen display, including the point of patient care. And, they can view structured electronic information and images simultaneously on the same screen. In addition, image-enabling lets users access electronic data and images from the same application--without switching between the imaging and CDR systems. This is a critical and often overlooked attribute of integration. Any system which requires the user to jump between two applications to access information is not truly integrated. Furthermore, for users who are more comfortable with either the CDR or imaging system's GUI, proper integration delivers the ability to access data from either. In this way, users need only master one point-and-click interface. Further, it allows the organization to archive data to optical jukeboxes for permanent, cost-effective, near-line storage and retrieval. Image-enabling can also bring workflow capabilities to the enterprise. Workflow is a powerful aid in the re-engineering of all work processes and automates the flow of patient information throughout the healthcare enterprise. Successful integration of an imaging system with a CDR should leverage the hospital's previous investments in information systems technology by minimizing the cost of additional hardware and software. This means that little or none of the current hardware and software would be needlessly displaced. In addition, it is important that the imaging technology be built according to industry standards and use open systems technology. The image-enabled CDR solves the patient record problem while giving hospitals and integrated healthcare networks the flexibility to choose the best of breed. The image-enabled CDR represents the first practical, multimedia approach to gaining control of the entire patient record. Fran Reynolds is the director of product management of LanVision, a leading provider of healthcare information access systems that enable hospitals and integrated healthcare networks to capture, manage, retrieve, process and store vast amounts of clinical and financial patient information. Please call 1-800-878-5262 for more information.
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