Internet-based records systems gives VA doctors more time with patients

COMPANY: West Roxbury VA Medical Center
PURPOSE: Integrate multiple data sources, be they legacy, relational or proprietary databases, into a single point of access utilizing Internet technology.

APPLICATION: "Host Project" -- In a hospital setting, one of the critical needs surrounding patient care is information, be it patient records, x-rays, CAT scans or other pertinent medical data. The quicker and easier data can be accessed, the better patient care will be.

At the West Roxbury Veterans Administration (VA) Medical Center in West Roxbury, Mass., a suburb of Boston, there are a number of different systems running on a bevy of platforms that support the facility's patient records. Plus, the system is connected to three other VA hospitals in the Boston area and the national VA network. The West Roxbury VA serves 22,000 area veterans and employs 1,700 people, including 100 doctors and 550 nursing services staff members.

Supporting and training these users on multiple applications, most running on older mainframe legacy systems, was a costly and time consuming venture for the I/S staff at the VA. Two years ago, Dr. Chukri Khuri, West Roxbury VA's chief of surgery, realized that his clinicians required access to all relevant patient data in one place that had accessed all information from all of the hospital's various systems and databases.

The project was also formed with the idea of being able to generate patient care and hospital performance reports more quickly, as well as the ability to integrate with other VA hospitals in the area to more easily share patient data, no matter where the patient was located physically.

A small team began a formal pilot project to bring all the systems together in a single, graphical interface, said Craig Miller, a biomedical engineer and one of the team's leaders. A Veterans Administration program called the HOST (Hybrid Open Systems Technology) Project, which rewards various development efforts that use commercial off-the-shelf products to produce innovative applications, funded the project.

"Our proposal was geared toward the integration of disparate databases," Miller explained. "Basically, taking multiple database systems and combing them into an intuitive GUI."


The quality of submittals in this category was outstanding. It was not an easy task picking a winner. The development of interactive applications using the web has come a long way in a short time because of the quality of the tools and browsers now available. Very sophisticated applications can be built quickly and effectively by small teams with small budgets.

The winner of this category, West Roxbury VA Medical Center, with its "electronic patient record", was a sterling example of this type of exploitation. It was a multiphased project to pull together disparate records, in multiple locations into a single, cohesive, transparent integration. The ultimate goal of the project was "a comprehensive electronic patient record, based on Internet technology that integrates database systems over a large geographic region." The finished application was a potpourri of data types including traditional text, imaging, voice, video data or combinations of each.

The end result was a "clinical cockpit" enabling clinicians to sit at any online PC and access information, regardless of platform or database, in order to make critical clinical decisions about patient care. It was a classic solution to a nagging business problem which resulted from innovative application of Internet technology. Our hats off to West Roxbury VA Medical Center.
Initially, the plan was to integrate three of the hospital's patient care systems through a type of client/server architecture. The three systems to be integrated included "Vista," a comprehensive, OpenMVS-based administration system used in some form by most hospitals; Numa, the VA's nuclear medical imaging system; and a proprietary relational database called Allbase that runs on the HP-UX platform. Eighty percent of the medical center's data is stored in legacy systems while the remaining 20% resides on disparate clinical database systems.

"[The challenge] was to combine a non-relational legacy system with two other database systems and pull into one view and have it be relational," said David Pike, chief of information resource management at the West Roxbury VA. (Pike is the "technical genius" at the VA, according to Miller.)

A team of 15 providers in the medical center's Clinical Users Group began the project by mapping out databases and considering how the various patient information could be presented electronically. Khuri, Miller and Pike worked on the intended integration design as well. However, the proper technology did not exist at the time to integrate the systems into a client/server model as planned, said both Miller and Pike.

The VA worked with the a number of vendors and consultants over the first year or two of the project attempting to find the silver bullet that would help solve their integration and presentation needs. Originally, a solution from Maynard, Mass.-based Digital Equipment Corp. was planned, but "their solution meant a lot of coding," Pike said. "We weren't prepared to code a home-grown system."

In the summer of 1996, the tool that the VA needed became available -- ISG Navigator from International Software Group Inc. of Burlington, Mass.

"Navigator allowed us to take advantage of ActiveX technology," Pike said. More importantly, it took advantage of the Web and browser technology that just begun exploding on to the marketplace. The original client/server system was scrapped in favor of an Intranet-based approach.

In late December 1996 and early January 1997, the project began in earnest with the help of ISG Navigator. Fortunately, the work of the 15-member panel for the Clinical Users Group was not wasted, as they continued to work with the project team to help build and advise on the Intranet system. The initial phase of the project sought to bring an integrated data access system to West Roxbury's mission-critical areas of the medical center such as the operating room and Intensive Care Unit.

A handful of developers, including Steve Merzlak from ISG, worked on the proof of concept project for a number of months. The team spent two months learning how to use ISG Navigator and its ADO/OLE DB access technology to its fullest. Merzlak was there to help with some of the coding and database integration work. "Merzlak was the real brains of the application. He worked on development from start to finish," Miller said.

Scotts Valley, Calif.-based Borland International Inc.'s Delphi development tool is used for backend development, while VBScript and SQL statements are used to make calls from the client to the various databases. ISG Navigator brings the databases together on the client side, according to Pike. For mainframe programming, Mumps is used for the medical systems.

"We had some problems with writing back into the database," explained Pike. "There are some unique business rules and stringent patterns of how to write stuff back. We had to get approval all the way down the line."

By utilizing Internet technology, the system can be easily extended to other VA hospitals. Two of the four Boston-area facilities were involved in the pilot, and more will be brought online in the future. "It became clear as hospitals merged that we could just consider the other hospital's database as just another disparate data source," Pike said.

- Jason J. Meserve


DR. CHUKRI KHURI, chief of surgery

DAVID PIKE, chief of information resource management

CRAIG MILLER, biomedical engineer

STEVE FISCH, president of ISG

STEVE MERZLAK, chief developer (from ISG)

ERIC DUBINER, professional group manager

Allows care givers more time with patients and simplifies data access, which also reduces overall hospital costs.

Active Server Pages

ISG Navigator (development environment)

Borland Delphi 3.0

Visual Basic 5.0

Windows NT 4.0

Dec Alpha (OpenVMS)


MS IIS 3.0

ISG Navigator

Number of proprietary legacy databases