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10/14/01 1 #7313: Kaleidoscope

Kaleidoscope:

The Use of

Wraparound Technology to

Form the EMR(

Ken Bobis, PhD

John Camoriano, MD

Mayo Clinic Scottsdale

HIMSS-2002

January 29, 2002

Atlanta, GA

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Speaker Background

Ken Bobis, PhD

� Chief Technology Officer / Director Advanced Technologies, Mayo Clinic Scottsdale

� 28 years in information Systems; 18 years in Healthcare

� Founded HIMSS-AZ, 1993

� Ph.D. in Computer Science

� University of Phoenix faculty since 1995

� BSIS, BSIT, MS Nursing, Nursing Informatics, & Online Campus

� WIU faculty member since 1993

� Past-Chair, Health Care Management, Information System

� Professor, Information Systems, Health Care MBA

� Keller Graduate School of

Management

� Estrella Mountain

Community College

� 6 other colleges &

universities

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Speaker Background

John Camoriano, MD

� Staff Physician and Assistant Professor of Medicine at Mayo Clinic Scottsdale (MCS) 12 years

� Chair of MCS Information Systems Steering Committee for 8 years

� Mayo Graduate School of Medicine with Board Certification in

� Internal Medicine

� Hematology

� Medical Oncology

� Oversight of Installation of over 37 new systems in 1998 in support of Mayo Clinic Hospital including;

� PACS

� EMR

� ICU EMR

� Member of Several Mayo Foundation Information Technology Committees and Task Forces for Internet, Security and HIPAA

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Additional Authors

• Jack Cranmer

– CIO, Mayo Clinic Scottsdale

– 31 years experience in Information Systems

– 15 years serving the healthcare industry.

• Troy Proudfoot

– Technical Analyst, Mayo Clinic Scottsdale

– 13 years experience in Information Systems

– Five years serving the healthcare industry

– Major developer of both Kaleidoscope & Apollo.

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Topics

• Background

• Initial Goals & Objectives

• Implementation Strategy

• Challenges Faced

• Problems / Issues

• Current Status of the Project

• Lessons Learned

• Questions

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• Largest private health care organization in the US• 2,000 physicians & 35,000 allied health staff

• 500,000 patients annually

• Locations

• Rochester, MN; Jacksonville, FL; Scottsdale, AZ;

• All organizations are “physician-led”

• Mayo Health System

• Serving more than 60 communities in Iowa, Minnesota, &

Wisconsin

• The “Three Shields”• Patient Care, Research & Education

• 30 individual organizations carry out the mission

The Mayo Foundation

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Expansion Background

• Mid-1980s: Mayo Foundation expanded to a more

national scope

• 1985: Mayo Clinic Jacksonville (MCJ) opens in

Jacksonville, FL

• 1987: MCJ purchased St. Luke’s Hospital

• 1987: Mayo Clinic Scottsdale (MCS) opens in

Scottsdale, AZ

• 1998: Mayo Clinic Scottsdale Hospital (MCH) opens

in Scottsdale, AZ

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The Mayo Clinic Scottsdale

Mayo Clinic Hospital

Mayo Clinic Scottsdale

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• Opened in 1987 by Mayo Foundation

• 250 Staff Physicians in 28 Specialties

• 8 Outpatient Practice Sites Including the Largest

Multispecialty Clinic in Arizona

• New 178 Bed Acute Care Hospital 10/98

• Basic Science Research Building w/ 6 Full-time Scientists

• Full Residency Programs in Medicine, Surgery & Family

Practice

• Started a Managed Care Product 1/98

• Annual Patient Visits to MCS 220,000

• Total Personnel ~3,000 FTEs

• Annual Admissions 4,000

The Mayo Clinic Scottsdale

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Mayo Clinic Scottsdale

Hospital (MCH)

• “High Tech. High touch” hospital in Phoenix

• One of the Nation’s first “paperless” hospitals

• Designed to include an entirely electronic medical

record (EMR)

• 15 miles from the Mayo Clinic Scottsdale

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IS Background

• Staff expanded from 30 to 100 to handle

increased hospital operations

• Selection of a Hospital Information System

(HIS) & all the departmental systems

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HIS Selection

• Cycare system had to be replaced

– not Y2K compliant

• New functionality

– common registration system, electronic medical record &

filmless radiology

• Legacy functionality (Mayo Clinic Rochester)

– Lab, radiology reports, surgical reports, clinical notes &

pathology reports

– An HIS by Phamis, Inc. was selected

• Phamis purchased by IDX, Inc.

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10/14/01 13 #7313: Kaleidoscope

Effects of the Vendor Buyout

• Opening of MCH set for October, 1998

– Would lose $1M for each day delayed

• IDX could not satisfy the requirements for

clinical results reporting

– Radiology reports, surgical dictation reports,

pathology reports, dictated clinical notes,

handwritten physician orders and notes,

miscellaneous reports (ECHO, EMG, ECG, PFTs,

etc) & outside records• All of this data was available in various systems in MCS & MCR

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Initial Goals & Objectives

• Medical Objectives

– Establishment of an EMR for both MCS and MCH• Provide a single view into the EMR

• Must be conducive to the Practice

• Users would include doctors, nurses, physician extenders,

secretaries & desk personnel

• Must be able to view and print from the same application

– To be the primary source for printing the medical record as

used in correspondence with patients, third parties & referring

physicians

– MCH to be an entirely paperless hospital• Physical plant did not allow for paper record storage

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Initial Goals & Objectives

• Technical Objectives

– Three-tiered client-server design

– Constructed with off-the-shelf Microsoft technology

– Utilize inexpensive personal computer hardware

– Provide a EMR “viewer” application• All patient data would remain in its respective source system

– The viewer will “wraparound” the disparate source systems

• Redundancy between MCS and MCH

• Named “Kaleidoscope” or “KScope”

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Kaleidoscope Architecture

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Implementation Strategy

• 12 month project timeline

• $200,000 budget

• Iterative, prototyping methodology

• Small development team (3 members)

– Internal Staff• Project Management

• Requirements

• Design

• Programming

• Contract Staff

– Programming

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KScope - Phase 1

• KScope - October, 1998

– Technologies

• Microsoft SQL Server v7.0

• Microsoft DCOM

• Microsoft MTS

• ODBC

• Windows NT Server 4.0

– Data Sources• Patient Demographics

• Clinical Notes

• Radiology Reports

• Surgical Notes

• Pathology Reports

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Initial Kaleidoscope Budget

Hardware (ten 300 MHz Personal

Computers $40,000

Testing Lab (Five 300 MHz

Personal Computers) 20,000

Software 10,000

Programming 130,000

Total $200,000

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KScope - Phase 2

• KScope - June 1999

– Technologies• DCOM replaced by Microsoft MSMQ

• Microsoft SQL Server v7.0

– Data Sources• ECHO

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KScope - Phase 3

• KScope - November 2000

– Technologies• Microsoft’s Dynamic Data Exchange (DDE)

– IMNET’s Object Broker application

– Data Sources• Scanned documents from IMNET / HBOC document-imaging system

– Other• A hardware upgrade was required

– Amount of active storage increased from 45 days to 3 years of images

– Clients increased from 115 to 4000

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KScope - Phase 4

• KScope - December 2001– Technologies

• Upgrade all hardware to Server Class Machines

• Pool database connections between users

• Limit the amount of data retrieved, but allow up to 5 years of data

• Cause “run-a-way” clients to “time-out” & cancel outstanding

• Reduce the network traffic by making all public message queue into

private ones

• “Pusher” load balancing. This is the server that allocates work to the

database agents

• Faster client-side COM component for Lab & Clinical Notes

– Data Sources

• Lab Results

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Problems Issues

• Instability of the application

– Local “crashes” when the local client workstation would

crash and have to be rebooted

– Global crashes when one of the servers (pushers or other

servers) would crash and have to be rebooted

– One episode of Kaleidoscope downtime every two

months with the average duration lasting three hours

– Often related to the unavailability of the source systems

– Resolution: Weekly reboots of the Microsoft NT servers

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Problems Issues

• Deployment problems

– Client-server architecture required direct access to

every workstation for each fix or software upgrade

– Resolution: Design modified to be web-based

• This effort took about 8 months to design, test and

implement, and was activated in fall 1999

• Time waiting for data

– Some queries took 10-15 seconds to complete

– Resolution: Time period parameter added to search

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Problems Issues

• No Remote Access

– High network traffic caused by the application design

causes application time-outs

– Resolution: Design modified to be web-based

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KScope Review

• Application reviewed by a major

consulting firm

• Findings

– KScope could not be scaled to meet the

ongoing needs of the organization

– Recommended to redesign Kaleidoscope

as a purely web-enabled application based

on Microsoft’s Distributed InterNet

Application Architecture (DNA)• Code named “Apollo”

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Apollo Architecture

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Apollo

• Web-enabled

• Federated Database is the primary system

data store

– Isolates MCS from two common problems

• The unavailability of the MCR systems due to an

unplanned outage

• Poor response time when a large amount of data is

requested

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Apollo Federated Database

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Apollo

• “One-time” load

– Data Transformation Services (DTS)

capabilities of Microsoft SQLServer 2000 will

be used to keep the data base updated in a

timely manner

• Architecture

– Microsoft’s Distributed InterNet Application

Architecture

– Windows 2000 Clustering and Load Balancing

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10/14/01 31 #7313: Kaleidoscope

Apollo

• Storage needs

– Initial data storage requirements were 27 GB

– 30% annual growth rate

• Storage Projections

– 2002 (35GB); 2003 (46GB); 2004 (60 GB);

2005 (77GB); 2006 (100 GB)

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Initial Apollo Budget

Hardware (Production & Quality

Assurance Environments) $120,000

Testing Lab 40,000

Software 20,000

Programming 330,000

Total $510,000

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Current Status of the Project

• KScope is the de facto EMR for MCS &

MCH

– In daily use by 1,700 users with excellence

acceptance

• From a temporary solution to a major production

system

– Accesses all Clinical data except patient

demographics & scheduling information

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Kaleidoscope Usage Statistics

Kaleidoscope Usage Statis tics

January through September, 2001

Document Type

Weekdays

(including Holidays)

Weekends

(including Holidays ) Total Requests

Clinical Notes 659,374 25,397 684,771

Radio logy 619,947 24,460 644,407

ECG 327,717 13,479 341,196

ECHO 108,824 5,310 114,134

Op Notes 345,196 14,316 359,512

Pathology 405,930 15,003 420,933

Total Requests 2,466,988 97,965 2,564,953

Average (per day) 2,235 207 1,627

High 5,417 845 5,417

Low 39 25 25

Note: a “request” is equivalent to a single inquiry for one or more documents .

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Application Strategy

• KScope to be a backup to Apollo

• IDX scheduled to release Document

Manager in 2003

• IDX will be the primary EMR Viewer, with

Apollo as a backup

– Users will favor one over another

• Inherent synchronization issue in the

maintenance of these dual environments

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Lessons Learned

• Explore the Vendor Product Life-Cycle

• Move Sooner to a Browser-Based User Interface

• Reduce the complexity

• Fast Track Development Can Work

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Questions?

10/14/01 38 #7313: Kaleidoscope

Kaleidoscope:

The Use of

Wraparound Technology to

Form the EMR(

Ken Bobis, PhD

John Camoriano, MD

Mayo Clinic Scottsdale

HIMSS-2002

January 29, 2002

Atlanta, GA