The University of Texas M. D. Anderson Cancer Center, integrating research and clinical care to serve 79,000 patients annually, wanted to improve the flow of its data. Because of its unique and sophisticated needs, M. D. Anderson chose to build an electronic medical record system in-house, with a service-oriented architecture to connect and display data using the Microsoft® .NET Framework. With the help of Microsoft Gold Certified Partner Avanade, M. D. Anderson implemented standards and processes to develop a sophisticated application to provide data to medical staff using the Microsoft environment. The system—and the IT department methodology it is built on—is flexible, highly secure, and scalable to support future growth. Most important, however, it has improved the productivity of M. D. Anderson medical staff, resulting in greatly enhanced patient care.
||What’s it worth to a patient to have his or her physician at the other end of the phone with instantaneous access to the CT scan that was completed this morning?
Vice President and Chief Information Officer
M. D. Anderson Cancer Center
The University of Texas M. D. Anderson Cancer Center seeks to eliminate cancer through programs that integrate patient care, research, prevention, and education. The center provides cancer care in the form of surgery, chemotherapy, radiation therapy, immunotherapy, and combinations of these and other treatments. Located in Houston, Texas, M. D. Anderson has treated more than 700,000 people since it was founded in 1944. With more than 16,000 employees, M. D. Anderson serves about 79,000 patients annually.
“In cancer, the world of research and the world of clinical care are intertwined very closely,” says Lynn Vogel, Vice President and Chief Information Officer at M. D. Anderson. “Developments can move from the research side to clinical practice even on a weekly basis.”
Managing that flow of information can be a real challenge, especially because, as Vogel says, “Cancer patients have a lot of data.” The data can include routine care, lab tests, radiology images, clinical protocols, and research protocols. He says, “Several years ago you’d see patients walking around the hospital pushing wheelchairs. The wheelchairs didn’t have patients in them. They had medical records in them.”
Because of this mountain of data, medical professionals’ productivity has long been hampered by the effort required to both find physical records and a particular piece of data within a record. “A nurse might have had to go to a radiology department film library to pull the film—and sometimes it would be off with someone else,” says Vogel. “Or the nurse or doctor would take half an hour paging through a physical medical record to find a particular lab result.”
So, early on, M. D. Anderson saw the need to move to electronic medical records (EMRs), which would both ease the burden of paperwork and improve the availability of data. In 1999, the center's Radiology department created an application called ClinicStation to integrate the presentation of radiology images with clinical data stored in a variety of IT systems. The application was written using the Microsoft® Visual Basic® version 6.0 development system and the Component Object Model (COM). Over the next six years, the center continued to enhance ClinicStation with new features, and it evolved into a complex workflow system.
But as M. D. Anderson sought a broader EMR strategy to include data other than radiology images, it found that commercial packages didn’t fit its environment. Most such packages were focused only on acute care and couldn’t integrate research data. Additionally, many had been first designed solely for outpatients, or solely for inpatients, and did not make a successful transition to cover both.
In 2005, M. D. Anderson decided to develop its own EMR environment in-house. The solution needed to be able to adapt to the center’s complex organization and workflow processes. But the effort as a whole had two additional key goals, says Chuck Suitor, the center’s Director of EMR Development and Support. “First, we wanted to make sure the architecture would support us for a good long time to come. We needed an infrastructure that could guarantee performance, scalability, and reliability.” The system needed to support not only growth in numbers of patients served and the amount of data on each patient, but potential new technologies and functionality.
Suitor continues, “Second, we had to ensure that our IT organization could grow. Historically we’d had an exceptionally small development team, three people or fewer, and now we needed a methodology and organization that could support a large team.”
Thus, M. D. Anderson didn’t need just a state-of-the-art EMR application. It needed an integrated set of technologies that would support continued, disciplined development of a system flexible enough to serve as the foundation for its IT strategy for years to come.
||We have built a software development factory that frankly I would stack up against any commercial software company, bar none. And it’s all built around Microsoft product offerings.
Vice President and Chief Information Officer
M. D. Anderson Cancer Center
One lesson M. D. Anderson took from the success of ClinicStation was the value of a service-oriented architecture (SOA), which treats services as components that work together to accomplish business goals. Indeed, that early version of ClinicStation, with its presentation of various types of data, had anticipated the industrywide move to SOA. “That experience laid the groundwork for us to move into SOA in a formal way,” says Vogel.
In early 2005, M. D. Anderson decided to build its new solution on SOA and the Microsoft .NET Framework. The .NET Framework provides a programming model and runtime for Web services, Web applications, and smart-client applications. The center selected the Microsoft environment because it wanted a set of technologies to provide a foundation supporting numerous existing heterogeneous systems and into which its different departments could integrate commercial software applications. “Such an ambitious project was only feasible with these kinds of tools now available that literally weren’t available even three or four years ago,” says Vogel.
A first step was to re-architect the ClinicStation solution using the new technologies. ClinicStation expanded to serve as the foundation for substantial future development. That expansion, however, required that the center develop common standards, tools, libraries, processes, and methodology to run a disciplined software development organization.
To assist in the development and knowledge transfer, M. D. Anderson chose in October 2005 to partner with Avanade, a strategic global joint venture of Microsoft and Accenture that specializes in solutions based on the Microsoft platform. Headquartered in Seattle, Washington, Avanade helps companies develop large-scale SOA systems to integrate heterogeneous IT environments. “The Microsoft and Avanade tools around .NET enabled us to easily support the latest standards in SOA,” says Suitor. “Also, Avanade had experience in building large-scale development teams, which was something we were very interested in.”
M. D. Anderson used Avanade assets including the ACA.NET architectural framework, Avanade Connected Methods (ACM) project management methodology, and ACA Lifecycle, which integrates ACM with the Microsoft Visual Studio® Team System development system and Visual Studio 2005 Team Foundation Server. The center also used application simulations from iRise, of El Segundo, California, to help construct new components.
In July 2007, M. D. Anderson completed the initial ClinicStation architectural rewrite. In the new system, still called ClinicStation, the SOA provides a common access framework for more than 40 back-end systems. M. D. Anderson takes a “best of breed” approach that gives different departments the prerogative to choose commercial software applications that address their specific needs. ClinicStation uses Microsoft BizTalk® Server 2004, part of the Microsoft Application Platform, to support viewing data and communicating with these back-end systems, allowing access to the data in place. Other components of ClinicStation also take advantage of other Microsoft products including Microsoft SQL Server™ 2005 database software; Microsoft Office SharePoint® Portal Server 2003; Microsoft Operations Manager 2005; the Visual C# 2005 language (as part of Visual Studio Team System); Internet Information Services version 6.0 for hosting Web services; and the Windows Server® 2003, Windows® XP, and Windows Vista® operating systems.
The new system serves about 10,000 unique users per month, up to 4,500 simultaneously. It offers 75 services, with 125 million service calls per month, and peak utilization topping 3,000 service calls per second. Its security infrastructure involves a shared token server to authenticate a user and client application. The security takes advantage of Web Services Enhancements 3.0 for Microsoft .NET, a Microsoft technology that provides developers with the latest advanced Web services capabilities to keep pace with the evolving Web services protocol specifications.
With its new EMR system development, M. D. Anderson has improved the accuracy of its data and quality of employees’ decision making; provided a scalable foundation for continued high-performance growth; increased the productivity of its medical staff; and lowered costs. “At the end of the day all of these benefits really accrue to the patient,” says Vogel.
||The Microsoft and Avanade tools around .NET enabled us to easily support the latest standards.
Director of EMR Development and Support
M. D. Anderson Cancer Center
Accurate, Instantly Available Data
ClinicStation now provides medical personnel with more data, more quickly and accurately. The original ClinicStation had a very rich set of features, and the newly written version had to ensure that every feature was as good or better than the original.
“Our care pattern involves intense two-day or three-day encounters with patients, who see various specialists and get all the diagnostic tests they need,” says Suitor. “But physicians want to have access to information on a patient when they are seeing the patient. So if newly created data was not instantly available, it would slow down the decision-making process in this series of appointments. This system makes everything instantly available to everyone.”
Furthermore, that data is accurate. “Every time you move a piece of data from point A to point B, you have a risk,” says Vogel. “The risks are that you’ll lose the data, or that point B will become out of date from point A. The SOA framework, where services expose or present data, eliminates those problems. When a physician looks at image data or clinical data in ClinicStation, he or she is really looking at that data as it exists in the host system.”
Flexible Scalability, Fail-Safe Availability
“We have created what we call a virtual repository here,” says Vogel, “and it makes the flexibility of adding new systems and new data sources extremely easy. That flexibility is facilitated by the SOA framework, because we don’t have to move data around.”
The new architecture has dramatically increased performance. “It’s really quite phenomenal,” says Suitor. “A single server on the new architecture can easily handle the load of our entire 11-server Web farm in the old architecture.”
The new architecture also has significant new safeguards in protecting availability. For example, M.D. Anderson has used Operations Manager 2005 to integrate a custom monitoring solution into ClinicStation, which helps the IT department see developing problems and resolve them before they affect users. “In medicine,” says Vogel, “you must have systems that do not fail. Because if they do fail, there are consequences, which ultimately end up on the shoulders of the patient. We take that extraordinarily seriously.”
Methodology for Continued Growth
“The institution continues to expand dramatically,” says Suitor. “In every measure—number of patients seen, clinic visits, surgeries, and revenue—it grows every year. While I don’t think we can claim ClinicStation is the only cause of that growth, it’s certainly a significant contributor.”
The reason is not just the system’s flexibility and scalability, but the IT organization that M. D. Anderson has developed to support it. “Our department underwent significant growth,” says Suitor, “with the development organization increasing from 3 people to more than 40, and we did so with real success.”
Thanks to technologies such as Visual Studio Team System and the methodology Avanade helped put in place, M. D. Anderson has large-scale development capabilities for new projects. “With our release management, version control, code libraries, and other capabilities, we have built a software development factory that frankly I would stack up against any commercial software company, bar none,” says Vogel. “And it’s all built around Microsoft product offerings.”
The result is a dramatic increase in productivity for the institution’s most expensive resources. “Historically,” Suitor says, “if one physician wanted to consult another, they’d have to go to the same physical location so they could look at the same images and data. Now they can talk on the phone and be looking at separate computers, but be looking at exactly the same thing.”
Because the system can also provide links for appropriate resources outside the facility, it’s not just M. D. Anderson medical staff who gain. Referring physicians, consulting physicians, and even patients have their own portals to relevant data. Vogel recalls one situation where an M. D. Anderson patient was hospitalized in London, and the physicians were able to share electronic images as part of a joint consultation. “In this example, it turned out there was no serious complication,” Vogel says, “so the patient was able to be discharged, rather than having to be operated on due to a lack of information.”
“We knew the institution would be counting on the features of ClinicStation, so performance and functionality were key areas of emphasis,” says Suitor. “The new version has exceeded our expectations.”
Furthermore, M. D. Anderson has used the system’s flexibility to improve its workflow. “For instance,” Suitor says, “if a drug utilization needs to be reviewed by a pharmacist before a patient can continue with care in the clinic, we don’t need to have a pharmacist standing right there to do it. The pharmacist can take care of it from wherever he or she needs to be operationally. This means we can keep the hospital and all of the clinics flowing much faster.”
The improved productivity has led to significant decreases in costs, though Vogel is reluctant to attach specific numbers to them. “We’ve had faculty here point out that if every physician who uses ClinicStation saves a half-hour a day (which is certainly reasonable), that has saved the center—depending on assumptions and calculations—$8–10 million a year. But the problem is, that $10 million doesn’t accrue to the organization’s bottom line.”
It’s a problem, however, only from an accounting standpoint, in terms of quantifying benefits. The benefits do exist—for patients. “What’s it worth to a patient to have his or her physician at the other end of the phone with instantaneous access to the CT scan that was completed this morning?” Vogel asks rhetorically.
He continues, “We have extraordinary statements from physicians saying they could not do what they do today in the absence of ClinicStation. It’s like those famous television commercials: the technology costs a few bucks and the staff time costs a few bucks, but when a physician stands up and says he couldn’t practice without this—that’s priceless.”
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Document published October 2007