“One of the biggest cultural changes this institution has ever seen” will hit the MUSC Medical Center later this year...

...as the first phases of the Oacis system expansion are put into production as part of the Electronic Medical Record (EMR) upgrade project.

“Change management hit our administration hard, but doctors continued to diagnose and treat their patients, and nurses cared for their patients much the same as always,” said Larry Afrin, M.D., chairman of the Oacis Expansion Project Steering Committee. But he expects the EMR system to hit the fundamentals of patient care like they’ve never been hit before. “Certainly not in the last 20 years while I’ve been associated with the Medical University.”

Afrin’s association with MUSC began in 1979 when, as a high school student, he was hired to program computers in the Department of Family Medicine. He is assistant professor of medicine in the Division of Hematology/Oncology and is physician liaison with MUSC’s Center for Computing and Information Technology.

Until now, doctors have been ordering tests, writing prescriptions and filling out charts with pen and paper. They write their notes or talk into a tape recorder, and other people transcribe the notes for them. The information is on paper and filed, and since 1993 much of it has been entered into the existing Oacis computerized database.

Hardware, software upgrades

When Oacis expands, first on the list will be the major upgrade of the Oacis software and the Sun Micro-systems data servers, the core database repository for the entire EMR system at MUSC. Mark Daniels, Center for Computing and Information Technology’s manager of patient support systems and project manager for the implementation of Oacis expansion, said that the present 1991-vintage server will be replaced by “the latest to hit the street. It’s a major jump.” That hardware upgrade combined with the upgrade of the Sun Operating System, the Sybase database management system, and the Oacis software itself will put MUSC light years ahead of its present electronic system operating on less-than-mediocre hardware.

In switching to the upgraded hardware and software, Daniels said users should not experience any interruptions. The entire new system will be installed and tested before it replaces the present Oacis system. All the data presently stored on the old system will be copied to the new before it goes online.

Creating connections

Then will come the push to interface as many sources of clinical data with the Oacis system as possible. Afrin said that although Oacis began in 1993 collecting laboratory and radiology data, encounter histories, and some kinds of clinical notes like discharge summaries, operative reports and cancer center transcriptions, plenty of other clinical data is still not feeding into Oacis. Among them are other clinical notes, pharmacy data, pulmonary function tests, EKGs—virtually anything done to a patient that results in a report that’s printed on paper and sent to Health Information Services.

“The biggest challenge,” Afrin said, “is not the installation of hardware and upgrading of software, but identifying all the sources of clinical data and developing the interfaces to feed them into Oacis.” These interfaces are mostly electronic, but sometimes procedural changes may be needed. Since May, Afrin’s committee has been identifying these clinical data sources and working on how best to get them into the Oacis system. University and College of Medicine strategic plans direct that MUSC’s electronic medical record be 90 percent complete by the end of the 1998 calendar year.

Data entry

The biggest change the Oacis expansion will bring to MUSC, Afrin said, will be electronic order entry and clinical documentation, the ability of MUSC clinicians to update charts, write prescriptions, order tests—everything they now do on paper—directly into the Oacis system from the patient’s bedside or close by.

“We have the data storage and reporting pieces of the system in place,” said Michael Irving, project manager for Oacis order entry and clinical documentation. “What we don’t have is direct user entry of orders and clinical documentation.”

“Nothing happens to a patient without a doctor’s order, and by improving that fundamental process, there will be innumerable benefits,” Afrin said. “Nobody should expect a change as big as this to be completely trouble-free, but it’s all being done in phases and there will be plenty of training available for everyone. After the initial adjustment, users will soon see the advantages.”

Irving makes sure MUSC clinician needs are met. He said that thus far, Oacis has been used primarily as a reference tool for physicians and nurses, but clinical information is also available on paper and, in some cases, through StatLAN. With the new system, there will be a far richer array of clinical information available in Oacis, and StatLAN will become obsolete. Irving and his team of analysts (CCIT’s Patient Care Systems team) meet with users throughout the institution to determine how best to configure the Oacis system to suit a wide variety of data entry and retrieval requirements.

The Patient Care Systems team develops specifications for configuring the system and passes them off to the programming staff on Daniels’ team to implement. Patient histories and physicals, vital signs, progress notes and any number of other pieces of information will be entered directly into Oacis by nursing, unit and clinic staff or directly via electronic interfaces. For example, clinical information will flow directly from the new physiologic monitors to the Oacis repository. Project goals call for all housestaff to be entering data electronically by the end of 1999, and all attending physicians to be doing so by the end of 2000.

As each unit and each clinic come live on Oacis, Statlan will be phased out. During the first six months of 2000, Statlan will be completely eliminated. All data entry and retrieval eventually will be accomplished through the Oacis CD (clinical display) or PMSI Practice Partner software. Afrin said that Practice Partner users will probably need to use the Oacis system for order entry, since even the upgraded Practice Partner system will not have that capability.

"Passport" to the web

To improve access to the Oacis repository, a web interface product called Passport will allow clinicians to view patient records theoretically from any workstation which has access to the web (such as with Netscape). However, Afrin said that Passport security will be tight to be sure that clinical data doesn’t flow over the Internet in an uncontrolled way.

“Although there’s no such thing as an ‘unhackable’ system, we are doing everything possible to provide the greatest convenience to clinicians while also taking the greatest reasonable measures to protect the confidentiality of the data,” Afrin said. Passport will only allow viewing of data. Entry of orders and clinical documentation will require use of the main Oacis program available only on clinical work stations on campus.

“Passport will also make it easier for referring physicians to get updates on their patients’ progress at MUSC, instead of having to wait for a report,” Afrin said. “Instead of our pushing the data out to them, they will be able to go online and pull the data to themselves.”