From Plug-and-Play Web-Forms to Physican-Extensible EMRS
Andrew P. Ho, M.D., (version 2005/2/11)
Abstract
OIO (Open Infrastructure for Outcomes, http://www.TxOutcome.Org) software allows clinicians, researchers, and other non-programmers to use their web-browser to create web-forms and assemble the forms into web-based data collection and reporting applications. Previously, OIO software has been used for quality improvement (Fong et al 2002, Tsuang et al, 2003), clinical research (De Luna et al 2004, Hindman et al 2004, Ho et al 2004), and hospital information management. While the OIO architecture has been designed to be user-friendly and flexible, deployment to busy medical clinics as electronic medical records systems (EMRS) was previously untested.
WRAP Family Services operates a network of 3 mental health clinics in Los Angeles County. In December 2003, the agency made a decision to replace their existing Macromedia Coldfusion (http://www.Macromedia.com) and Microsoft (http://www.Microsoft.Com) SQL Server-based medical records system with an OIO-based system. The user-friendly forms editor, modular architecture, low startup and long-term costs, and free/open-source software license were the main factors cited for this decision.
WRAP staff obtained training for creating OIO forms and a development server was installed by January 2004. Data migration from the legacy system into OIO progressed as forms were designed and approved. WRAP clinical and administrative staff were trained to use the OIO system and the official switch-over to the new WRAP.OIO server occurred in May 2004. Custom reports and automated workflow procedures continue to be created and incrementally improved.
WRAP staff have been using the OIO system for day-to-day clinical, human resources, and accounting information management tasks over the past 6 months. During this time, the OIO system has been immune from worm-related service disruptions that have plagued Microsoft-powered patient information systems operated by other mental health clinics in Los Angeles County. Furthermore, OIO's unique configurability and flexibility continues to enable WRAP agency to satisfy ever-changing mandated data collection and reporting requirements. Total cost of ownership (TCO) in terms of staff time and information management expenses are less than $100 per staff/PC per month.
With the successful dissemination of OIO technology to WRAP, we plan to replicate deployment of OIO as electronic medical records system to other sites. For future sites, WRAP staff who are already familiar with OIO will be able to provide training and deployment support.
Background
Electronic medical information systems are complex information tools that serve diverse and changing needs during their life cycle. Local customization and ongoing updates are essential for the medical system to support unique and evolving requirements. New billing, reporting requirements, as well as new medical knowledge and evolving standard terminology drive a near constant need to change the information system. Traditionally, expert software engineers and programmers work closely together with clinicians, administrators, and other domain experts to perform these essential customization and update tasks. This process of customization and ongoing maintenance is arguably the most expensive and unpredictable aspect of the medical information systems deployment.
OIO (Open Infrastructure for Outcomes) system provides web-browser accessible, user-friendly tools for creating and changing medical information systems. Easy customizability begins with a through-the-web-browser forms editor. Question items and responses are defined through user-friendly web interface. A full range of data types such as images, files, date, time, text, number, and categorical values are supported. Sophisticated data entry widgets such as visual analog scale and hip range-of-motion are also available. Advanced form controls such as conditional item skipping, revealing, linked responses, and mandatory responses can be defined through the advanced form controls module. Additional data types and data entry widget can be easily added to the OIO system. Through these easily customizable web forms, non-programmers can create and customize data collection and management systems. Clinicians and administrators can perform local customization and ongoing modification of the medical information system with little or no software engineer or programmer involvement. Furthermore, these web-forms can be imported and exported as plug-and-play XML files. Forms-packs that include a collection of forms represent a data management application. These forms and forms-packs can be downloaded from a forms library and become “executable” forms once loaded into a recipient information system.
WRAP Family Services (www.wrapfs.org) operates a distributed network of three psychiatric clinics and provides extensive case-management and outreach social services in the Southern California region. Founded in 1997, WRAP mobilizes over 50 staff FTE and delivered more than 23,000 client-encounters to over 2500 clients in 2004.
WRAP’s first information system is a proprietary practice management solution (PMS) built with Microsoft Access technology. It worked adequately except the vendor went out of business by 2000. Thereafter, system cannot be updated to manage new contracts nor handle rapidly changing billing requirements, which forced WRAP staff to revert to paper-based accounting and using Microsoft Excel spreadsheets. By 2001, WRAP invested in an in-house project to develop a web-based PMS based on the Coldfusion platform and Microsoft SQL Server database technology. Once completed, WRAP intended to market the resulting system commercially. A team of 2 consultants, an in-house programmer, and a project manager achieved a prototype system was put into production by mid-2003. The prototype system included only the patient registration module with additional modules scheduled for rollout every 4-6 months. WRAP staff noted numerous bugs due to the alpha-status of the system, which significantly interfered with their daily work. Furthermore, projection for completing the development and migration to the new system was an additional $250,000 over the next two years.
Methods
Milestones: In December 2003, WRAP staff had an opportunity to see a one-hour demo and presentation of the OIO system and subsequently selected WRAP.OIO as their “Replacement PMS”. A consulting contract was negotiated and finalized in January 2004 to develop, train, and migrate WRAP from its two legacy systems to a new OIO-powered EMRS. Working closely with WRAP staff, forms design training was completed and a development server was activated in January 2004 within days of contract signing. WRAP staff successfully created over 30 OIO forms and began validation of data migration procedures by February 2004. In May 2004, the WRAP.OIO system went into live production, successfully replacing WRAP’s two legacy systems.
Currently, WRAP.OIO provides nearly all of the essential practice management, clinical health records, and billing functions. Additional billing, administrative, human resources, and quality improvement forms and reports are being added as necessary.
Hardware/Software Specification
Hardware:
Server: Two P6-3GHz PC-servers, one for data entry, one for report generation
Daily remote backup to stand-by server
Client: 60+ P5-700+Mhz PC-workstations
Software:
Server: Debian Gnu/Linux, PostgreSQL, Zope, OIO-1.1.0 with 50+ forms, 30+ reports, Automated and User-activated full-backup
Client: Windows 95+ or Debian Gnu/Linux, Mozilla or Microsoft IE web browser
Network: 10Mbps Intranet, 2Mbps Internet connection between the 3 WRAP clinics
Costs: Less than $100 per month per staff/PC
Results
WRAP staff were trained to create OIO forms that specifically fulfill the data management needs.
Forms Creation
* List of Forms
* Edit a Form
* Edit a Response on a Form
* Edit a Question on a Form
As the forms are created, they become accessible for data collection via a user-friendly interface.
Using Forms
* Web interface for selecting form to complete
* Web interface for selecting patient from patient list
Specific reports were built for rapid access to information collected and organized via the forms.
Custom Reports
* Reports organized by department
* List of custom reports (Part 1 2 )
* Administrative reports
1. Selecting a billing report
2. Selecting a financial report
3. Benefit enrollment
4. United Way contribution
* Clinical reports
1. Retrieving progress notes by parameter
2. Progress notes display
3. New clients
4. Client List
5. Units of Service Log
On-going modification and creation of new forms and reports by WRAP staff allow the information system to fit changing clinical needs and reporting requirements.
Conclusion
Implications:
1.The OIO system is capable of rapidly and robustly replacing orphaned information systems that are based on Microsoft technology.
2.The OIO team has the requisite skill-set, motivation, and commitment to manage and deliver complex IT solutions on time and on budget.
3.It is feasible to train and equip non-programmer staff to create forms and generate reports to support ever-evolving information management needs.
A consequence of applying a sufficiently rich and uniform meta-data infrastructure to applications is the ease of creating simple but powerful data transformation and reporting tools. With adequate meta-data, report generation can be increasingly automated and intelligent. In other words, data from one application or system can be more easily understood by another application or system. Creation of billing reports from medical information is one example of reporting automation. Spreadsheet software simply does not provide adequate meta-data handling. For example, there is no standard way of annotating spreadsheet columns and rows beyond a few data/content type attributes. Traditional relational database systems also fall short for the same reasons. Currently, users can only pick from flexible but inadequate systems such as spreadsheets and relational database or inflexible but automated systems such as specialized medical billing software.
OIO is different in capturing much richer meta-data at the time of "forms" creation. The end users think they are just creating web-forms but actually OIO is capturing meta-data in an uniform and structured way. Then, the OIO system takes advantage of this meta-data infrastructure to support form-to-form translators that provide semantic translation between forms. Altogether, the OIO system combines a powerful data modeling foundation (forms editor) with an ontology builder (form-to-form translators), workflows engine, reporting, and scheduling tools that can be re-configured without use of traditional programmers. The resulting system is as flexible and easy to reconfigure as spreadsheets and yet much richer in capabilities.
The OIO system can be used to build web-applications for business, eCommerce, and research data management. In the clinical domain, physicians and other non-programmers can change the "base" OIO system to describe new disorders, treatments, insurance plans, and related workflows. This capability changes the relationship between physicians and the information systems that they rely on. Users of OIO systems become active collaborators and participate in tailoring the information tool to fit their specific needs. This may be the only way to satisfy the diverse and rapidly changing needs of the multitudes of medical specialties and practice environments.
References
1. Fong T; Tsuang J, Ho AP: Factors related to Poor Contact of Discharged Dual Diagnosis Patients from a Psychiatric Emergency Room, Addictive Disorders and Their Treatment, 2002, 1(3):81-88.
2. Tsuang J; Fong T; Ho AP: Dual Diagnosis and Treatment Compliance, Psychiatric Services, 2003, 54(4), 576.
3. De Luna S; Hindman DW; Smith MW; Lin K; Smith J; Ho A; Subjective vs. Objective Measures of Compliance to a Smoking Cessation Program among Patients on Antipsychotic Medications, 2004(118), NCDEU, Phoenix Az.
4. Hindman DW; Smith MW; Lin K; Ho A; Smith J; De Luna S: Exploration of the Effect of Smoking Cessation/Reduction on the Positive/Negative, and General Psychiatric Symptoms of Patients on Antipsychotic Medications, 2004(116), NCDEU, Phoenix Az.
5. Ho A; Hindman DW; Smith MW; Lin K: Real-Time Identification of Missing Data in a Forms-based Protocol Management System, 2004(36), NCDEU, Phoenix Az.
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