Ward Keever says he doesn't have much use for the Internet.
But in his effort to bring medical information to clinicians, Keever plans to make a basic World Wide Web technology known as a browser as common at University of Pennsylvania Health System as stethoscopes.
There's no contradiction here. Penn's chief information officer and his staff are turning the technology that simplified Web travel to another use. Browsers enable the pooling of information from multiple databases, even ones crafted in different computer languages, into a variety of multimedia formats.
But instead of using browsers to travel the Internet, Penn and other health systems are using them within the confines of their own emerging networks in configurations called "intranets."
For Keever, the immediate aim is to speed integration of the Penn system, even as it continues to develop its Philadelphia-area network.
That's a big project, but it's only the beginning.
Browsers eventually will be tapped to deliver clinical information at the point of care. In providing the means for this, browser technology may become the Swiss Army knife of healthcare improvement-the all-purpose tool to reshape clinical practice by providing just the right data at just the right time for a diagnosis or decision.
As important, Keever says, the familiarity of the Web format will work in Penn's favor. "We are trying to facilitate the practice of medicine. We are not trying to make (clinicians) computer literate," Keever says. "We need to put up systems that are easy to use, that have a five-second learning curve."
A few miles away, computer professionals at Crozer-Keystone Health System in suburban Philadelphia already are serving up access to clinical information. The Crozer-Keystone project provides patient information and laboratory results to 316 physicians in a read-only format wherever they have a computer. Before long, the system will allow the physicians to transmit information, too.
Crozer-Keystone is using modem connections to telephone lines, but early next year Web-style technology will be in place, says Richard Carroll, vice president and CIO at the Media, Pa.-based system.
In the meantime, Crozer-Keystone plans to move its Web-based information service, which isn't used for sharing patient data, off the Internet itself. Instead, the system will work within a national, healthcare-only network being developed by the Irving, Texas-based VHA hospital alliance. The VHA network operates similarly to the Internet, but it works in a separate arena with security and collaboration features specific to healthcare providers (July 7, p. 42).
Tool for change. Like most developing healthcare systems, Penn and Crozer-Keystone are undertaking their information initiatives against the backdrop of continuing shifts in their numbers of owned and affiliated physician practices and facilities.
Nationwide, information systems departments are struggling to order the patchwork of incompatible computer capacity resulting from rapid consolidation of the delivery system.
The ultimate goal is to make the power of medical data and innovation available across the many sites of a healthcare delivery continuum.
Many information experts are finding that browsers and other Internet-style technology are tailor-made for their volatile environments, says Steve Rushing, an information systems consultant at the Atlanta office of Andersen Consulting.
"The Internet itself was conceived and designed to survive in the midst of chaos. And the intranet is a straight derivative," Rushing says.
Up until now, the problem has been that basic organizational changes had to happen at integrated delivery systems before an appropriate computer network could be built, he says.
Everything-from the substance of software programs to the placement of computer terminals-depended on getting to systemwide seamlessness, a goal all providers are pursuing but few, if any, have achieved. Any progress in integration easily could be set back with the introduction of yet another provider partner.
The advantage of Internet-style technology is it "doesn't force (health systems) to make the hard, hard changes in the chaos before (they) at least start to achieve some of the benefits of connectivity and collaboration," Rushing says.
Adopting familiar Web browsers "will lead to acceptance of new ways of doing things" without massive information system makeovers that force more change than a system can handle yet, he says.
Role model. A simple illustration of browser technology's potential is occurring at Jefferson Health System, another Philadelphia-area network.
Jefferson computer pros have designed a way for clinicians to get to all the systems they need through a single computer screen called the "role-oriented workstation." The tool not only simplifies computer access but also authorizes access to multiple systems based on the identity of the computer user.
That's an important improvement. It brings order to a jumble of separate computer systems, says telecommunications expert Michael Gorsage, a senior manager in the Atlanta office of First Consulting Group.
Previously, Jefferson clinicians had to log on and off different systems, key in password authorizations each time and generally slog through an access jungle to do their jobs, Gorsage says.
The browser model doesn't affect what happens once clinicians get into a particular information system, but "you're using the technology to make it easy for people to get at stuff," he says. "If you make it easy for people to use information, they'll use it."
Jefferson has customized 13 role-based screen presentations. They vary by physician specialties, educational settings and nurses' duties, says Michael Perino, lead information technology engineer.
When a clinician sits down at a terminal and logs on, the system knows what "role" to bring up based on the inputted password and displays different information depending on the user's job.
A high-powered computer server authenticates the log-on and generates a screen similar to an Internet home page, complete with click-on links to the computer applications to which the user has access, Perino says. The browser even knows to send e-mail to that terminal.
Wherever, whenever. Besides simplifying navigation through different systems, use of a browser means clinicians' computer encounters are consistent no matter where they are in the system, says Al Giacomucci, Jefferson's chief technical officer.
And the browser can play programs remotely over a modem connection, Giacomucci explains. That means a clinician can work at home or in an office on a computer much less powerful than normally needed. The computer doesn't even have to be wired into the network.
The technology gives Jefferson new options in its quest for easy access to comprehensive information. And that's important given how complex the Jefferson system is, says its interim CIO, Walt Zerrenner, who was brought in from Superior Consultant Co. of Southfield, Mich., to spearhead the retooling.
The flagship of the Radnor, Pa.-based system is 607-bed Thomas Jefferson University Hospital in Philadelphia. The system also includes nearby 279-bed Methodist Hospital, three suburban hospitals, a primary-care network, a physician-hospital organization, a home-care business, and assisted-living and rehabilitation units.
Penn's Stephen Smith explains that with browser technology clinicians get a window to system data at the point of care, ready access to administrative information and a search engine for reference material-all in one place. Smith is project leader for clinical systems at the Penn system.
Although Penn isn't using browsers yet, it plans to. Its computer pros have been charged with bringing order to the system, beginning at 649-bed Hospital of the University of Pennsylvania in Philadelphia. Penn wants to connect academic medical and primary-care activities at several facilities on- and off-campus.
Its ambition is to bring the teaching hospital's medical prowess to the hundreds of places where physicians diagnose and treat people.
Connecting affiliates. Not only do integration efforts have to cover a system's various clinical pieces, they also have to deal with differing levels of affiliation. And they have to be technically ready for new integration with each deal the system makes.
At Penn, the system will organize its information system around an inner ring of owned facilities and practices and an outer ring of affiliated partners, Keever says.
Besides the Penn hospital, system-owned components include Penn's medical school, an 800-physician multispecialty group practice, a 300-physician primary-care practice and 273-bed Presbyterian Medical Center of Philadelphia. A merger with 471-bed Pennsylvania Hospital in Philadelphia is pending. The Penn system also has a management services organization for affiliated physician groups, home-care agencies and other organizations.
For owned facilities and physician groups, a sophisticated "electronic nerve system" is in the works. But affiliated partners are just as important to the continuum of care and need to be included in the information loop, Keever says.
Thus, he and his staff are working to create an information system that quickens and standardizes integration while minimizing the change initially required of clinicians. After all, although clinicians may be using different information systems, they may have a smooth operation they don't want disrupted.
The Web browser is one tool in the overall effort, Smith says. It helps standardize information exchanges while allowing new additions to the system to run much the way they always did, Smith says.
And Penn can minimize investments in non-owned facilities with Web browsers because of their ability to take orders and get computing power from a central operation. Among other things, that conserves expenses for personal computers that have to be crammed with software and visited by technicians for upgrades and trouble-shooting, Smith says.
Ultimately, the plan is to move Penn's information systems away from a traditional organization around facilities to an organization based on the clinical and business relationships necessary for managed-care contracts and capitation risk, Keever says. That strategy blurs differences among affiliates, subcontractors, joint ventures and acquisitions. Otherwise, attempts to differentiate the healthcare system based on market price, customer service and new products could be impeded, he says.
Data-driven medicine. Once Penn has a handle on the internal organization, it can roll out the big guns-disease management programs and computer systems that target the best medicine to vulnerable populations. That's meant to take advantage of the intellectual capital of Penn's medical research by bringing data-powered medical management to every corner of the network, Smith says.
Clinical thinking and research are competitive edges to exploit, "but from an (information systems) perspective, we are very much trying to keep up with that clinical sophistication," Keever says.
The challenge will be to get disease management out to where it can do some good, says Richard Cramer, manager of clinical systems at Penn.
Web technology will be an interim step to get the newest advances out quickly, while computer pros work on the main network, Cramer says. An electronic medical record operating in a high-speed telecommunications network is the ultimate goal. But in a short time, an intranet can step in as a mechanism to spread medical knowledge throughout the system-first with static, bulletin-board messages and eventually with more interactive features, Cramer says. Those will make it easier for clinicians to get directly to the data they want.
As the system spreads geographically, however, Penn doesn't plan to go outside a network of leased telephone lines and private cables to connect far-flung facilities with the Internet. "The Internet isn't necessarily the future," Keever says, while emphasizing, "I'm a strong believer in use of the intranet."
A foothold, fast. Meanwhile, a Pittsburgh-based healthcare system expanding with a vengeance in Philadelphia is using all the "net" it can get to quickly integrate and compete with Penn, Jefferson and Crozer-Keystone.
The system is Allegheny Health, Education and Research Foundation, which is about one year into a four-year, $50 million project to connect its Philadelphia-area sites to each other and to a brawny data center.
But the system must overcome problems caused by "a lot of diverse technology," says Daniel Walsh, CIO in that region. Its effort includes ripping out core reporting systems, for such departments as registration and laboratory, and standardizing replacements across facilities, Walsh says. Those core systems will be integrated with each other and then hooked to a "lifetime clinical record" information system.
AHERF recently acquired Graduate Health System, a Philadelphia-based system of six hospitals, and other area healthcare properties, extending its reach statewide. A fast conversion of core systems is crucial because two-thirds of the system's facilities now are in Philadelphia, Walsh says.
And the system's work force is massive-31,000 total employees, including 4,000 faculty members teaching 3,200 students. To get information to them, AHERF is "making a significant investment in browser tools," Walsh says, for use on both the Internet and an internal intranet.
Instead of having to convert thousands of computers to high-capacity, high-power varieties and service them individually, a browser setup makes lower-class personal computers and Macintosh computers just as capable, Walsh says. And they can be maintained from a central point through server computers running Web-oriented software.
But browsers won't magically increase access unless they can be linked by lines and cables (See related story, p. 58). Between a fourth and a third of that $50 million project cost is committed to technology infrastructure, which includes but isn't limited to browsers, Walsh says.
The Internet can be used to create quick benefits while other systems are under construction. For example, AHERF is working to provide its clinicians universal access to e-mail at home and on the road as well as in the office this year.
In many cases, the system won't have to provide clinicians with anything but access authorizations. That's because the Web-based network will use whatever Internet-accessible tools the clinicians already have, Walsh says.
Complementary strategies. A short drive west into Delaware County, Crozer-Keystone already has a high-speed, high-capacity communications connection to most of its sites within an 84-square-mile area. Compared with AHERF, Crozer-Keystone is a well-oiled machine, information-systemwise.
More than 300 miles of fiber-optic cable run through about 100 buildings and surrounding real estate to a Bell Atlantic fiber-optic network connecting all the sites.
The network installation, begun in 1992, combined with implementation of more than 50 computer applications, puts Crozer-Keystone well ahead of the typical system.
It already includes comprehensive access to information through modems and telephone lines, accomplishing much of what other systems are seeking to do with Web-style technology.
That feature has allowed doctors to dial in for information anywhere they happen to be, says John Zapp, M.D., chairman of the department of family practice at Crozer-Chester Medical Center in Upland, Pa. Zapp is Crozer-Keystone's physician point man for its Physician Office of the Future initiative, which will use browsers to make information even more accessible.
The package allows physicians to gain access to such information as test results, orders, patient history and documented emergency encounters, CIO Carroll says.
But for all its progress, Crozer-Keystone still has a few miles to go. Its final goal is to put information in the laps of all clinical foot soldiers, such as home-care workers and home medical equipment suppliers.
Intranet technology is being tapped to assist a sophisticated automation of physician offices that includes multimedia, voice messaging, fax, intranet and Internet packages, along with linkages to the Crozer-Keystone integrated network.
The system's developing intranet will expand existing capabilities to coordinate care between physicians and other important contacts, says Ann Bagnell, vice president of marketing.
That way a physician can execute a referral for home care and be confident a patient will have an oxygen tank and whatever else necessary upon returning home from the hospital, Bagnell says.
Beginning early next year, physicians will be able to submit as well as view orders. That's the first step in a series of two-way interactions made possible by Web innovations and culminating in the use of emerging software called "pull" and "push" technology, Carroll says.
Based on information preferences "pulled" from people via surveys sent to their Web addresses or other tools, information from many places can be sifted, tagged for destinations and "pushed" to electronic addresses,
Rather than initiate searches for every bit of information needed on a patient, for example, a physician can get the browser to automatically conduct routine requests, says Briggs Pille, senior manager in the Chicago office of First Consulting Group.
Information on current patients is scattered throughout a system's network, from the laboratory and radiology department to the nursing floor.
With push technology, Pille says, such data could be gathered on schedule each night, organized by patient and delivered to a Web page each morning-just when the doctor is looking for it.