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