How the Obstetrics department of Norton Hospital built a new system to help gather and analyze its newborn infant information.
These days, more and more companies are turning out mission-critical client/server applications that collect and retain valuable corporate data. As client/server technology continues to mature, the faith of corporate IS in open systems becomes stronger. As a result, more legacy and paper-based systems are being put to rest in favor of better ways to manage information.
Alliant Health System, a not-for-profit hospital corporation headquartered in Louisville, Kentucky, decided it needed a better way to gather and analyze a very precious collection of data -- its newborn infant information from the Obstetrics (OB) department of Norton Hospital in Louisville (one of the hospitals Alliant owns and operates). Both hospital personnel and Alliant's corporate IS department agreed that two areas needed improvement:
According to Dr. Jonathan Weeks, the former chairman of the OB department at Norton, the situation was ripe for introducing new and improved methods of collecting patient information. But any new system had to be conceptualized and implemented correctly from the outset. "It was important that any system be designed with physician and nursing input from the beginning. It needed to be tailored to the way we deliver patient care," says Weeks. Although several vendor packages were reviewed, none seemed to meet the particular requirements of the medical facility. In the fall of 1994, the OB department decided to build a system from scratch. "With off-the-shelf packages," notes Weeks, "you normally can't record data that is unique to your own situation." At this point, Norton's OB staff partnered with Alliant's corporate IS department to build the new application.
"To compete in a managed-care environment, Alliant must build strong relationships with health-care providers across the continuum of care," says Nendorf. "Creating reliable and complete information will be critical as we move to more automated processes, such as the electronic medical record."
To create the new client/server infrastructure, a small team of IS personnel at Alliant carefully selected the components that would make up the company's first mission-critical client/server system. Billy Bosworth, one of the lead developers with the effort, says the thought process started at the client workstation end. Bosworth explains, "Because the workstations were going right in the delivery rooms where family members are often present, securing access to the data was high on the requirement list. Further, the system would have to be extremely robust, as well as flexible, to handle the demands of our client/server application. That's why we decided to go with Windows NT Workstation 3.51; we just couldn't trust this type of a system to a DOS/Windows 3.1 environment."
In addition to using Windows NT Workstation for the client level, the team also chose Windows NT Server 3.51 as the database server platform. To hold the hospital's OB information, the group agreed on the Oracle7.2 database, which would run on Windows NT. The Oracle database was a natural fit for the project, notes Reiners. "We were already using Oracle to hold data we collect from our psychiatry and surgical oncology areas. We knew that one day we would want to consolidate all of the information into a corporate data warehouse, and making Oracle one of our standards made sense."
To maximize Oracle's performance and reliability under Windows NT, Bosworth and the other team members carefully crafted the server to meet the expected heavy load. The group opted to use a hardware RAID 5 setup on the IBM model 720 100MHz Pentium server, which came equipped with 128MB of RAM, and everyone involved has been pleased with the results. "For OLTP database systems, the RAID architecture really shines," notes Bosworth. "With a non-RAID setup, you have to split your database files manually across the machine's drives to avoid I/O contention -- and even then, without multiple controllers, you can still have a bottleneck. With the RAID 5 setup, even though we still have only one controller, we treat all of our drives as one single disk, and all of the redundancy is handled very efficiently at the hardware level."
The RAID system also proved useful to protect against data loss. "With RAID 5, if we lose one of the drives, the machine will notify us that the drive is defunct and will continue as normal," says Bosworth. "Because we use the hot swappable drives in the server, we can pop the bad drive out, put the new drive in, and begin a rebuild of that drive while our users continue to work. We've tested this on occasion and have been amazed at how little, if any, performance hit we take." Because the new OB application is a 24X7 system, the RAID structure is used in conjunction with Oracle's hot backup capabilities to provide maximum protection of the data.
To develop the front-end GUI, the team chose Powersoft's PowerBuilder 4.0 for Windows NT. Although Alliant used Microsoft's Visual Basic previously for a few small applications, the IS team felt that it lacked some of the robust database features that the new OB system would need. The team was impressed with PowerBuilder's DataWindow technology and the built-in client/server database support that other 4GL tools lacked. "If you ask me what tool I would choose to write straight Windows programs with, I would say Visual Basic," states Bosworth. "But if you ask me what tool I'd use to write Windows database applications, my overwhelming choice is PowerBuilder." The group estimates that the total hardware costs for the database server, along with the developer and user workstations, came to nearly $100,000. Software costs fell between $20,000 and $30,000.
The larger, complete OB system effort began with data modeling sessions conducted by Alliant's IS team and several OB nurses, along with Dr. Weeks, the OB department's chair. "It was important to get the prime decision makers, and people who knew what was needed, together for these sessions," notes Bosworth. "Without them, we'd be shooting in the dark."
Mattingly was particularly excited about what she saw. "There is so much redundancy in what we do now, and a lot of time that could be spent with patients is taken up by filling out duplicate sets of information. The new system should let us concentrate more on the people."
Using Powersoft's S-Designor Enterprise 4.0, the team conducted modeling sessions using a workstation connected to an overhead projector that displayed the model on a conference room screen. This approach worked very well with the end-user audience. As each session ended, the graphic model was printed out from S-Designor for the participants to study before the next session. "S-Designor was an integral part of our effort and was indispensable in the beginning," says Bosworth. The product, however, was not without its flaws. The team ran into numerous problems in trying to use the S-Designor repository that stores data models in a relational database for archival and retrieval. In addition, the product failed to generate all of the PowerBuilder attributes correctly into the Powersoft catalogs for development purposes. The team hopes that the latest release of the product, version 5.1, will perform these functions correctly.
Once the conceptual data model was agreed upon, the group created a physical design with S-Designor that was used to build an Oracle database. "When all was said and done, we ended up with nearly 80 tables that should hold close to one gigabyte of information after a year," says Bosworth.
With the physical structure of the database in place, the small IS group began to turn its attention to the PowerBuilder application. Instead of starting with the specifics of the OB system, the IS staff began to rough out a reusable set of objects that could be used for the OB application as well as other applications to come. "The object-oriented capability of PowerBuilder was one of the reasons Alliant chose this tool," says Bosworth. "We knew we first had to build a reliable framework that could be used later on for other projects. Because of this, our first project took a little longer than other successive projects should. Fortunately, our director [Nendorf] and manager [Reiners] understood the importance of this approach and gave us complete buy-in."
The IS group constructed a PowerBuilder base class library comprised of 20 to 30 objects that would be used for the new OB OLTP system. Once this framework was in place, development of the actual OB system began. "When you see a base class library in action, you really begin to appreciate the power of encapsulating database and business logic in objects and then inheriting them to produce specific components of a system," says Bosworth.
After about two months' work, the major pieces of the application were put in place. The IS staff then installed a Windows NT workstation to beta-test the application in one of the nursing units being used by Mattingly and other nurses. The entire group believes that such close-knit testing led to the success and acceptance of the new application.
At this juncture, however, the group encountered several difficulties regarding the deployment of the OB system. Two immediate problems presented themselves: the performance of Alliant's network and the difficult accessibility of the delivery rooms. The group had originally intended to have the workstations in the delivery rooms execute the PowerBuilder application from a central server located on the network. After testing by the IS group, that plan was quickly dismissed. "When we benchmarked local versus network executions, it wasn't even close," states Bosworth. "The number of router hops to get to the server, in addition to the heavy load that our network already experiences, mandated a local install of the application." It was critical, the group believes, to perform this type of testing at the actual client sites to see the performance of the system through the eyes of the end users. Without such on-site testing, unacceptable performance problems would have resulted when the system was released into production.
The second issue was gaining access to the delivery rooms to install both the Windows NT workstations and the OB application. Heavy patient traffic made the initial installations difficult and raised concerns about deploying upgrades and fixes of the OB application. To help with the initial installations of the Windows NT workstations, the group preconfigured all of the workstations ahead of time and placed them in a secure location close to the OB wing of the hospital. When a delivery room became available, the nursing staff notified Alliant's help desk, which quickly installed the configured workstations in each room.
The group uses two mechanisms to help install new versions of the OB application in each room. "We use the built-in networking features of Windows NT to gain access to each remote workstation from a central code server," says Bosworth. "When we have fixes to apply, we can either send them over to each workstation manually or utilize Microsoft's System Management Server to replicate the software out to where it needs to go automatically."
To facilitate the process of software builds, the group broke down the OB application into five PowerBuilder dynamic libraries, which helps on two fronts. "Because our project has nearly 350 PowerBuilder objects associated with it, we didn't want to go through long executable builds each time we put in a fix," said Bosworth. "By breaking down our PowerBuilder libraries and grouping our objects by functionality, we can produce a relatively 'skinny' executable, which helps speed application startup. Having a number of dynamic libraries helps, too, because each time we make a change, we only have to rebuild that DLL instead of re-creating the entire .exe."
Once live data began flowing into the new OB system during the summer of this year, the analysis of the data that Dr. Weeks had longed for began to materialize. "We built special OLAP capabilities into the application," says Bosworth, "so Dr. Weeks could examine the data in ways he couldn't before. For example, we can produce graphical layouts of the hospital's C-section versus vaginal delivery rates and let him drill down into each area to discover which doctor groups are responsible for the overall makeup. He can then drill down further to find the actual doctors performing the procedures."
Another feature particularly appealing to Weeks was recently demonstrated to the hospital's OB physician staff. Instead of manually writing delivery notes (which contain the doctor's description of a patient's delivery), the new OB application lets the doctors review delivery information entered by the nursing staff. If all is correct, the physician can click on a button to produce a formatted delivery note that can then be printed for retention.
Other plans are being made to link remote physician offices with the new OB system. A number of offices want to send their patient's prenatal information to the hospital in electronic format so that the data can be online for the hospital staff upon the patient's arrival. The IS staff is reviewing a variety of methods on how to establish such links, including using the Internet. (Alliant recently activated its own site on the Web at www.allianthealth.com.)
Dr. Weeks would like to see a few other things as well. "With our customized system, we can build in more and more capabilities to improve the efficiency of staff and quality of care. For example, I would like to see the physician orders for incoming patients linked in so that prescriptions for drugs would be immediately sent to the pharmacy."
Although the OB system is up and running, the IS staff is quick to note that the work is far from over. Interfacing the legacy systems to the newer applications will become more and more complex as new client/server systems such as the OB system are developed. And with the rapidly changing health-care industry, the systems must remain flexible to handle whatever the future holds. Still, the most difficult challenges could be the non-technical ones. People must be willing to learn the new systems -- and that means training. Training takes time, and unfortunately, time is not something of which hospital staffs have an abundance. With the OB system, Alliant has taken that first big step into the future. The road is now paved for more mission-critical client/server success stories for the company.