A Cloud-Based Electronic Health Record Platform

Henry Chueh, MD, MS闕 思 杰METS 2012

November 11-14, 2012

Health Care30%

(n=150) Data from CDW Tracking Poll 2011

What about clinical applications?

BarriersSecurityPrivacy

Compliance

IncentivesCost

AccessConsolidation

Delivery

Transition

Agility

1999

Millennium bug

Emergence of XML

Netscape dies, IE thrives

HTML 4.01

OncallAn informatics platform to meet MGH’s clinically-related operational and research needs responsively, effectively, and efficiently

Oncall goalsBe a user-driven platform

Support a common clinical record and integrate with existing systems and data

Support highly specialized workflow

Foster research on its technology and the clinical processes it supports

OncallCloud-based

Web browser clientService-oriented architecture

CoStAR EMRest. 1978

1981 users

178,037 patients

1,522,879 structured notes

CoStAROncall

Data Services

Application ServicesXML

{ private cloud }

HTML

M database

SQL database

bulk

App / Presentation

App / Business

Data

Request Flow

Oncall: host to manyElectronic health record (EHR)

Discharge ExpressApprentice (Handoffs,

Signout)iHealthspace

TopCare Population HealthClinical Research toolKit

Anesthesia Pre-opProfessional Billing

Cardiac Lab OperationsCardiac Surgery Inpatient

Transplant Registries

Embryology LabObstetrics record

Neonatal BilicurvesSurgery Registries, M&M

Mobile workflow

…and many more

Oncall usage growth

2006 2007 2008 2009 2010 20110

20000000

40000000

60000000

80000000

100000000

120000000

140000000

160000000

Volume

Page

hit

s

Oncall usage growth

2007 2008 2009 2010 2011 20120

20

40

60

80

100

120

140

Concurrency

Hit

s / s

ec (

peak

)

ScalabilityDatabase

External servicesSessions

Chaining services

SessionsCookies or databaseReduced memory needsAvoid self-blocking

1

RecursionParallel requestsSingle server pool

2

Chaining services

3

ResultsOncall EHR

Discharge Express

Apprentice

iHealthspace

Instead of “applications”…

…focus on content and workflow

Oncall as EHR

Oncall “brands”Primary Care (IMA/APF/NEHC)

CardiologyCardiac surgery

Transplant ProgramFertility

ObstetricsReproductive endocrinology

Infectious diseaseAnesthesia

Emergency surgerySurgery

Vascular Center

>5,000,000 documents>1,000,000 patients

Structured Notes“High blood pressure. Increase lisinopril for sustained high

systolic readings.”

“Inactivate cough. Resolved.”

“Pulse 75, BP 156/84, Weight 210.”

<PROBLEM> <CONCEPTID SCHEME=‘ICD9’>401.9</CONCEPTID> <RECORDEDNAME>Hypertension</RECORDEDNAME> <COMMENT> Increase lisinopril for sustained high systolic readings. </COMMENT> ...</PROBLEM><PROBLEM> <CONCEPTID SCHEME=‘ICD9’>786.2</CONCEPTID> <RECORDEDNAME>Cough</RECORDEDNAME> <COMMENT>Resolved.</COMMENT> <STATUS>INACTIVE</STATUS> ...</PROBLEM><VITALSIGNS> <PULSE>75</PULSE> <SYSTOLICBP>156</SYSTOLICBP> <DIASTOLICBP>84</DIASTOLICBP> <WEIGHT>210</WEIGHT> ...</PROBLEM>

ElectronicHealthRecord

Direct Data Entry

Clinical LanguageUnderstanding

OutsourcedTranscription

Transcoding

“Correctionist”

>75%

Oncall

Concepts by Year

SmartDictationOncall EHR

CoStAR EMR

Discharge Express

2005 2006 2007 2008 2009 20100

10000

20000

30000

40000

50000

60000Dictation Online

Dis

char

ge S

umm

arie

s (t

otal

)

ApprenticeHandoffs

Signouts

Progress notes

3700 users, 47 groups

Apprentice

2007 2008 2009 2010 2011 20120

200

400

600

800

1000

1200

Daily Tasks

Task

s cr

eate

d / d

ay (

avg)

Apprentice

…and ~1,000,000 daily progress notes in 20122008 2009 2010 2011 2012

0

10000

20000

30000

40000

50000

60000

70000

80000

Signout NotesSi

gnou

t no

tes

/ mon

th

iHealthspace

iHealthspace

iHealthspace

Oncall

Data Services

Application ServicesXML

{ private cloud }

JSON

Acknowledgements

Octo Barnett, MD

Faculty and Staff,Laboratory of Computer Science

Thank you谢谢