In Search Of Health Care's "Holy Grail"

It's called the 'Holy Grail' of medicine - a birth-to-death medical record. Sequoia Software of Columbia, MD, is on a crusade to create a system capable of delivering it. "Most people's medical records are fragmented. For instance, I grew up in a different part of the country than I live in now, and I don't have any idea where the medical records from my childhood are," says Jeff Mason, director of sales at Sequoia Software Corporation.

"Having complete lifetime medical records available over a computer network would benefit everybody in the medical industry," continues Mason. "It would allow a physician to track the illnesses and the treatments a patient has had over the years. This would help physicians with diagnoses and preventive plans. Insurance companies could use lifetime medical records both for underwriting clients and for better tracking of managed care procedures. And imagine the database of outcomes of specific procedures that could be created by assimilating information from a library of birth-to-death medical records."

Steps In The Right Direction
Sequoia has not found the "Holy Grail" yet, but is taking steps toward it. One of its installations recently helped Kaiser Permanente of Ohio win the Davies Award, which is presented by the Computer Patients Records Institute in recognition of an organization's ability to successfully use computer patient records to improve health care delivery.

Kaiser Permanente is a nationwide network of managed care outpatient clinics with 13 regional bases. The Ohio region has 12 sites throughout the state, which service 250,000 members. Working with Kaiser, Sequoia designed a system that collects patient information and connects it across the 12 distributed sites.

"A patient may generate the bulk of his records at his primary home site," says Mason. "But if he is referred to a specialist at another site, records will be generated there. If the same patient has an emergency near another site, that could end up generating records at a third site. With Sequoia's system, patient records can be stored at the site where they are generated, or they can be automatically shipped electronically to the patient's primary site. Either way, the records can be accessed (in a less than two-second retrieval time), at any of Kaiser of Ohio's 12 sites."

Distributed vs. Centralized Storage
Sequoia's system differs from other major hospital installations in its distributed records approach. "Most other hospital systems have a centralized record base," says Mason, "which creates a strain on the network when multiple users are trying to access the mainframe or server that is storing all the records. With a distributed system all the users are not accessing the same location. They are automatically accessing whichever location is storing the data that they need."

A distributed system is also more in line with the vision of birth-to-death patient records. "Eventually we see medical records being available over some sort of intranet, where they could be accessed through a search engine," says Mason. "Internet technology is being used to connect proprietary electronic storage systems right now. Look at all the resources that are currently connected through the Internet."

Sequoia uses a "connection manager" to link the different sources in its installations. "A ‘connection manager' allows users to interchange information among systems that operate independently otherwise," says Anil Sethi, Sequoia's chief technology officer. "This allows users to leverage legacy systems into their current applications."

For instance, hospitals have traditionally used mainframes to store demographic, billing and other patient data. Instead of asking a hospital to abandon its mainframe in order to install a client/server environment as a platform for a document management system, Sequoia integrates mainframe and client/server systems with a connection manager. A connection manager is also used to connect systems at different locations. Sequoia also works with whatever client/server platform a facility may be running. "A hospital could be using a Mac or PC environment, running Windows 95, 3.1, NT, or whatever else," says Mason. "We are able to integrate it." According to Mason, Sequoia's biggest strength, though, is its ability to organize the information in these systems so it can be accessed efficiently and seamlessly as one record.

Doctors Embrace Imaging
Imaging is currently Sequoia's method of choice for entering information into its systems. "There is a lot of paper being used, and it is not going to go away. We've found imaging to be the best way to convert paper documents to electronic format," says Mason. Imaging also is a favorite among some of Sequoia's most demanding end users. "Doctors love imaging," says Mason. "Because of the dynamic environment they work in, doctors can't afford the time to sit down and enter data on a keyboard. Today doctors are being encouraged to see more patients than ever, and anything that slows them down can hurt their practice. "Imaging allows them to fill out forms with the pen and paper that they are comfortable with, and doesn't force them to perform any data entry tasks."

Document Management
Sequoia installs systems that do more than merely image documents, though. Sequoia integrates its own workflow, document management, and Master Patient Index (MPI) software, MedStar, with the imaging system, to create an organized record system. In the Kaiser installation, for example, there are more than 4 million records stored online, indexed by such information as patient name and number, and date and type of appointment. Data extracted from these documents through OMR (Optical Mark Recognition) is also shared on-line, allowing, in Kaiser's case, complete demographic tabulations for all of Kaiser of Ohio's members.

Forms Library Begins Document Imaging Process
Kaiser's document management process starts at the forms library which electronically stores forms for different types of encounters (the term Kaiser uses for a clinical appointment). "When the patient checks in for a podiatry encounter, for instance, the forms for a podiatry encounter can be printed out. The physician fills out the forms during the appointment. On each form are fields where physicians' notes can be handwritten, and other areas where the physician can make marks that can be read by OMR technology."

OMR Assists Billing, Pharmacy, Etc.
Information derived from OMR marks includes data that can be used for patient demographic calculations, billing, pharmaceutical orders and lab information. "If a patient has a broken arm, for instance, there might be a box on the encounter form, under the diagnosis category, that the physician can check off for ‘broken arm'. If, to treat it, the physician sets and applies a cast, there might be a box under the procedure category that would be checked off for that," says Mason. "When the form is scanned, the information in the boxes is read through OMR and routed through workflow to the appropriate applications. Based on the marks, the billing system, for instance, can generate a bill, the demographic database can be updated, and the pharmacy can receive the appropriate information to prepare a prescription."

Indexing Images To Be Retrieved As A Virtual Record
After the data is extracted, the document images are automatically indexed by Medstar using patient information included on the form and forms recognition software. The images are stored in a network of servers accessible (in less than a two-second retrieval time) through any of 1,000 workstations at Kaiser's. Eventually, Mason says, Sequoia plans to index X-ray, MRI and other images used for diagnoses with the patient record. "X-rays and MRIs can be viewed as just another document," says Mason. "Our goal is to make the all diverse pieces of a patient's medical record accessible through one distributed system."

Focusing On Health Care
In addition to installations in the medical industry, mostly in outpatient environments spread across more than one geographical site (similar to Kaiser or Ohio), Sequoia has installed systems for Black & Decker and the Virginia Department of Transportation (VA-DOT). "Our system is applicable in any environment where a user wants to take pieces of information from several sites and look at it in one comprehensive picture," says Mason, "but our focus is in healthcare.

We think, of all markets, electronic records are most important to the health-care industry because of the importance of information for treating patients and for managed care.

"Traditionally, health care has also been behind most other industries when it comes to adopting data entry technology, because it has been impractical and burdensome for doctors to enter data into a system. Imaging and document management has provided a solution to this."