In five years, leading-edge medical centers will look much like the University of Texas M.D. Anderson Cancer Center in Houston looks today. The cancer center, ranked in 2008 by U.S. News and World Report as the nations top hospital for cancer care, has built a visionary electronic medical record (EMR) systemthe first of its kind anywhere in the worldthat seamlessly integrates clinical and research information. The system, called ClinicStation, redefines healthcare record keeping and represents a major advance in healthcare.

The new system is pioneering in seven important ways:

	It is the first EMR system to provide an interoperability foundation between clinical and research information--a capability that will significantly improve both patient care and research. The best decisions can be made about a patient's treatment utilizing the latest cancer research.

	It is the first hospital to fully deploy custom-built EMR technology from scratch on such a large scaleit involved 100 developers, encompasses 70 modules and now processes up to 4,000 service calls per second during peak periods and approximately 325 million calls per month.

	The system uses a full Service Oriented Architecture (SOA) and the Microsoft .NET Framework, representing one of the most fully implemented SOAs in the healthcare industry.

	ClinicStation provides an integrated view of each patient that's available to authorized participants in the clinical and research chain. Most hospitals keep medical images and data in separate systems; at M.D. Anderson, separate systems are presented through SOA as an integrated working environment.

	The new system is flexible, growing and changing to meet M.D. Anderson's needswithout hampering daily operations. Uniquely, physicians and others in the healthcare chain provide the leadership in introducing new capabilities. 

	It demonstrates that the interoperability and flexibility made possible by SOA has the potential to improve any industry challenged by information maintained in disparate systems.

	Already ClinicStation is serving as a model. M.D. Anderson allows other institutions to view and learn from the system, promoting M.D. Anderson's role as a leading teaching institution. 

In 1999 M.D. Anderson established itself as a leader in the use of electronic medical records when it built its original ClinicStation, a system that gave physicians and other healthcare workers convenient and timely electronic access to patient's records. In 2003, the legacy ClinicStation was recognized with a Computerworld Honors Laureate. But in 2007 the cancer center envisioned a significantly improved system that would provide a host of new capabilities, like the ability to integrate research data, include data from virtually every electronic source within the institution, and provide for the integration of both outpatient and inpatient data. Because no commercial software allowed for such capabilities and for interoperability, M.D. Anderson took the unprecedented step of developing the customized application itself. 

Today the SOA environment encompasses all of M.D. Anderson's patient data, everything from patient diagnosis and treatment to clinical trials research and pharmaceutical data.  No other system is as comprehensive or built to easily enable development of new capabilities suggested by healthcare providers. ClinicStation boosts workflow, enabling physicians to handle more patientsand with more informationand greatly reduces the time spent looking for data or images. Patient care has been improved: physicians now can make faster and better-informed decisions from any location, 24/7. By integrating clinical and research data, ClinicStation is making an invaluable contribution to M.D. Anderson's mission to end cancer. It serves as a model for any healthcare institution because the future of medicine will require the linking of clinical and research data and the incorporation of new data forms as we are finding with genomic analysis. 

Because of its unique and sophisticated needs, M. D. Anderson chose to build an electronic medical record system in-house, with a Service Oriented Architecture to connect and display data using the Microsoft® .NET Framework. The .NET Framework provides a programming model and runtime for Web services, Web applications, and smart-client applications. The cancer center selected the Microsoft environment because it wanted a set of technologies to provide a foundation for the integration of numerous existing systems, many of which are commercial software applications. Such an ambitious project was only feasible with the kinds of tools now available that literally werent available even three or four years ago, says M.D. Anderson Vice President and Chief Information Officer, Lynn Vogel. 

M. D. Anderson needed an integrated set of technologies that would support continued, disciplined software development -- flexible enough to serve as the foundation for its IT strategy for years to come. The challenge was to connect 60 different back-end systems into a single comprehensive presentation and analytic capability while creating an environment that facilitates the addition of modules now and in the future.  The field of medicine is constantly changingnew data models, new treatments, new discoveries of biological processes, new genetic relationshipsand M. D. Anderson is leading the way with an EMR system that is responsive to new developments.

The Centers IT department had two technical goals, says Chuck Suitor, Director of EMR Development and Support. First, we wanted to make sure the architecture would support us for a good long time to come. Second, we needed an infrastructure that could guarantee performance, scalability and reliability. The system needed to support not only growth in numbers of patients served and the enormous amount of data and radiology images gathered to treat each cancer patient, but also potential new technologies and functionalities.


The choice of SOA was critical to the success of the new EMR system. SOA, which treats services as components that work together to accomplish business goals, enables interoperability for the exchange of both data and images between the clinical and research departments.  It also provides the flexibility to easily customize and add features as the needs of M.D. Andersonand the field of medicine more broadly-- change. SOA enables a common access framework for all current and potential sources of patient data.  M. D. Anderson takes a best of breed approach that gives different departments the prerogative to choose commercial software applications that address their specific needs.  Now the data from these systems appears to the clinician as a single working environment.

The early version of ClinicStation, with its presentation of various types of data, had anticipated the eventual move to SOA. While many organizations have expressed interest in SOA, most still are in initial stages, planning, prototyping, or perhaps setting up a single application. At M.D. Anderson, however, the new ClinicStation is not just an application with SOA. Its the foundation of a service-oriented enterprise. 

ClinicStations success refutes popular industry assertions that SOA cannot support large organizations. The proof is that on a routine basis, there are 7000-8000 users of the system. The new system serves about 13,000 unique users per month and up to 4,500 users, simultaneously. 

Among the innovations of M.D. Andersons new electronic medical record system is the development process itself. The software development methodologylike the EMR systemis flexible, highly secure, and scalable to support future growth. The cancer center used a software factory concept that allows M.D. Anderson developers to build and customize the software when commercial software doesnt meet the centers unique needs.

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ClinicStation represents a major advance for M.D. Andersons patients, caregivers and the research community. In the past, physicians endured a lengthy process of tracking down and retrieving patient data or radiology images. Time delays slowed the process of treatmentsometimes stalling important medical decisions. Meanwhile, difficult access to the data hampered the ability of consulting physicians to collaborate on patient cases. The process of incorporating research data into the care process was equally challenging.   As a result, M.D. Andersons top researchers were unable to fully benefit from the knowledge gained in the clinical realm and clinicians could not take advantage of research findings that would help them deliver the best possible patient care. 

With ClinicStation, M. D. Anderson has improved the accuracy of its data and the quality of care givers decision making. It has provided a scalable foundation for continued high-performance growth. It has increased the productivity of its medical staff and lowered costs. At the end of the day, all of these benefits really accrue to the patient, says Dr. Kevin McEnery, Professor of Diagnostic Radiology at M.D. Anderson.

Historically, if one physician wanted to consult another, theyd have to be in the same physical location. Now, they can consult over the phone, while looking at the same data and images on their computerseven across state, local or international boundaries. 

Because the system also provides links for appropriate resources outside the facility, its not just M. D. Anderson medical staff who benefit. Referring physicians and patients have their own portals to relevant data. Vogel recalls one situation where an M. D. Anderson patient was hospitalized in London and the physicians were able to share electronic images as part of a joint consultation. In this example, it turned out there was no serious complication, Vogel says, so the patient was able to be discharged, rather than having to be operated on due to a lack of information. 

Our care pattern involves intense two-day or three-day encounters with patients, who see various specialists and get all the diagnostic tests they need, says Suitor. But physicians want to have access to information on a patient when they are seeing the patientor before. So if newly created data were not instantly available, it would slow down the decision-making process in this series of appointments. This system makes everything instantly available to everyone with a need to know.

In the past, patients charts were so heavy that patients at times required wheel chairs to carry them from one place to another during the tests and consultation process. Wheel chairs no longer are neededcharts are available electronically for physicians and caregivers. 

The system has delivered many important benefits. Among them:

	Data accuracy. When a physician looks at image data or clinical data in ClinicStation, he or she is looking at the most up-to-date data, in the originating system so that a system of record data integrity is preserved.  

	Flexibility. Adding new systems and new data sources is extremely easy. That flexibility is facilitated by the SOA framework, because we dont have to move data around, says Vogel.

	Increased performance. A single server on the new architecture can easily handle the load of the entire 11-server Web farm in the old architecture.

	Stability. A custom monitoring solution helps the IT department see developing problems and resolve them before they affect users. 

	Increased Productivity. The flow between the hospital and all of the clinics is much faster.

	Reduced Costs. By some internal estimates, every physician who uses ClinicStation saves a half-hour a day, every day. 

Dr. Garrett Walsh (Professor, Thoracic & Cardiovascular Surgery): 
ClinicStation allows us to compare radiographs, previous CAT scans or MRIs to measure tumor response to see if they are improving with treatment or not.  The computer will link the images and we can go down slide by slide, slice by slice and make a decision as to whether the tumor is growing or not. That was virtually impossible before, even with hard copy films, because you would be looking at one film trying to compare it to the other and getting out your ruler. ClinicStation gives us the ability to magnify images, rotate images and use all sorts of imaging alterations to better define what is going on in someones chest, brain, abdomen or long bone.  We, as surgeons, are extremely dependent on having reliable radiographs available at all times. Fortunately, ClinicStation has been an extremely reliable system for us.  I could not imagine practicing medicine without ClinicStation.

 Dr. Ron Walters (Professor, Breast Medical Oncology):
ClinicStation is very much my lifeblood as far as everything we do in the clinic and also as far as research goes.  Whether Im at home or at work, I can look ahead to see the schedule for the next day, anticipate the problems I might be having, whos coming in, what kind of situation they are in and kind of map out how that day is going to go so that it doesnt hit me by complete surprise the mornings when I come in.  One of the biggest advantages that the outside world suffers from is the cross-coverage for other physicians, or even getting adequate follow up for my own patients when I am offsite.  ClinicStation, because of its architecture, is web based.  I can perform almost everything I do from home, except, of course, examine the patient. This includes responding to questions, looking up medications, ordering medications, writing out chemotherapy orders--anything that needs clarification is easily done at home or actually from any place where, with proper security, I have access to ClinicStation.

 Dr. Randall E. Millikan (Associate Professor, Genitourinary Medical Oncology):
The business of academic oncology is about making it possible for the next generations of patients not to have the same prognosis that todays patients have, requires information technology especially in this current era when research information and genomic information is exploding.  This is a huge challenge. Whats ironic is that it is easier to measure the expression of 500 genes in a 100 tumor samples than characterize in a structured way the clinical characterization of those patients and their clinical follow up and clinical outcome because the clinical side of the house lags far behind in the ability to generate structured information. So people who work at MD Anderson who just cant stand not knowing what causes cancer and how to cure it need ClinicStation in order to do this work.

Through its Outbound module, currently under development, MD Anderson is planning to add to ClinicStations current online access for patients and their referring physicians, resulting in direct access to virtually all of contents of the online medical record.

One of the major breakthroughs with ClinicStation is that its SOA provides the foundation for the integration of research and clinical data, inpatient and outpatient data. This is the first time a hospital or research institution has gained such a capabilitythe new system solves the interoperability problem that has plagued institutions with siloed sources of data.

Today, all of a patients information is available to every authorized caregiverphysicians, researchers, radiologists, lab technicians, pharmacists and others. For the first time, providers have complete and convenient electronic access to a wide range of patient information. In the legacy systems, physicians and others could do little more than view informationusing different passwords, presentations and even navigation tools. Now they can create information, add orders for treatment, and fully interact with the data and imageswhile the data remains in the source system. These are significant achievements in healthcare and they ensure that M.D. Anderson remains a premiere and visionary cancer treatment and research facility. ClinicStation fosters unmatched levels of collaboration, increases the pace of research and patient care, strengthens decision-making, streamlines workflows, lowers costs and improves the patient experience. 

The systems use of Service Oriented Architecture is unique in the healthcare industry. No other hospital here or abroad has used the innovative technology at such a scale or with such success. Among the many benefits, SOA helps deliver unprecedented data accuracy.  Every time you move a piece of data from point A to point B, you have a risk that youll lose the data, or that point B will become out of synch with point A, explains CIO Vogel. The SOA framework, where services expose or present data, and then consume data, eliminates these problems. When a physician looks at patient data in ClinicStation, he or she is really looking at that data as it exists in the host system.

Most hospitals use commercial EMR systems and don't perform in-house development of this magnitude for such a mission-critical application. Not only did M.D. Anderson undertake the unusual challenge of creating custom-built technology, it also innovated a development model that is unique in the healthcare industry. 

M.D. Andersons software factory model started out with the challenge of re-platforming a legacy system and has expanded into a sophisticated development model for adding functionality to the EMR platform through multiple parallel development efforts. The aim is to deliver new capabilities to physicians, nurses and clinicians as fast as possible. And it is working beyond anyones expectations. Unlike commercial systems, which typically require feature prioritization across multiple customer sites, ClinicStation was designed so that M.D. Andersons own internal resources can add the capabilities. 

We have created what we call a virtual repository here and it makes the flexibility of adding new systems and new data sources extremely easy. That flexibility is facilitated by the SOA framework, because we dont have to move data around, says Vogel. 

The new architecture also introduces significant new safeguards. For example, M.D. Anderson has used Microsoft Operations Manager 2005 to integrate a custom monitoring solution into ClinicStation, which helps the IT department to identify potential system issues and resolve them before they affect users. 

And because the new system demonstrates the potential for SOA to scale to serve the needs of a major institution, it sets a new standard  showing how the technology can power a Service-Oriented Enterprise in any industry. 

MD Anderson has won a number of awards for its innovative use of technology. Appendix 1.
Please also find a ClinicStation Video Case Study in the link below:  http://www.avanade.com/_wmv/MD_Anderson_750k.asx

Building the new and highly complex ClinicStation EMR system over the course of an 18-month transformation meant overcoming numerous challenges. Perhaps the biggest obstacle was the fact that the new system needed to be developed without disrupting the legacy system and its operations, all while the legacy system continued to be enhanced with new functionality every three monthsand that new functionally needed to be available in the new, re-architected system as well.

It is always difficult to build a system to the scale required by M.D. Anderson. That challenge was multiplied when the institution made the daring decision to use custom technology and start from scratch. It meant scaling up from a three-person development team to an army of 100 developers at the height of the program. The dimensions of the program were staggering and unmatched by any hospital here or abroad: no fewer than 60 back-end systems needed to be connected into a single comprehensive, services oriented architecture.

At the same time, developers needed to create a process for adding individual modules now and in the future. When the effort began, ClinicStation operated had about 30 modules. Today it has expanded to encompass 70 modules demonstrating healthcare industry thought leadership including:

Order Set Management:
This module automatically creates, manages and routes chemotherapy order sets to the appropriate recipients along with the patients medical context, hence increasing efficiency, reducing adverse events and improving overall patient safety.

Structured Clinical Documentation (SCD): 
This module addresses one of the most challenging areas in medicine -- adding structure to clinical documentation that was previously only captured in free-text format.  SCD enables the capture of this information in a discrete manner to support critical care decision analysis, while improving accuracy and speed for data entry by physicians so that they can spend more time on patient care. 

Medication Reconciliation: 
This module accurately and completely reconciles medications across the continuum of a patients care, hence decreasing the potential for medication errors. 
 
Nursing Needs Assessment:
This module allows a nurse to document and automatically route a patients need for--or request from--the ancillary services of the Institution (e.g., Social Work, Nutrition, Physical & Occupational Therapy, Wound Ostomy & Continence, Chaplaincy, Speech & Audiology, Case Management, etc), hence improving the overall patient experience.

The project required the discipline and structure to release new functionality every three months. The new ClinicStation system now has triple the functionality of the legacy systemall introduced in eight separate releases.

M.D. Andersons Services Oriented Architecture permeates the historical wall that has separated research and clinical care departments and has allowed the development of processes for integrating inpatient and outpatient data as well as radiology images and data. It also meant building a system that would accommodate emerging clinical and research needs like personalized genomic medicine, in which clinicians and researchers will draw heavily from a patients genetic makeup in the development of both diagnoses and treatment regimens. Genetic data represents a major departure from the type of data historically used to assess patient conditions. The new system needed to be constructed to accommodate this move towards personalized medicine, which requires gathering and tracking a complex database not only of clinical data, but of genomic data for each patient. Another major difficulty: incorporating images into the systema challenge developers with commercial vendors have struggled with for years, but one M.D. Anderson was able to overcome by relying on SOA.

And the very decision to pioneer Service Oriented Architecture in healthcare created its own major hurdle. Developers could not look to trailblazers experience for guidance  M.D. Anderson was the trailblazer. 

The major obstacle was the bold decision to defy healthcare industry convention as well as M.D. Andersons history and build its own electronic medical record system from scratch. M.D. Anderson turned its back on 20 years of investing in its legacy architecture for the promise that a new architecture  Service Oriented Architecture  would dramatically change the way it delivers cancer treatment and researches ways to eliminate cancer. 

The standard in virtually all of the healthcare industry today is to purchase commercial application suites from one of a small number of companies, which base their applications on architectures that were introduced 15 to 20 years ago.   In every case, these companies have been challenged to incorporate new forms of data, such as images, into their base products, and none have yet done so seamlessly. M.D. Anderson views image integration as only the first example of significantly greater challenges already presented by the introduction of genomic or personalized medicine. Given the thin margins that commercial healthcare software companies experience, they are understandably reluctant to re-architect their systems to take advantage of the many benefits of SOA; M.D. Anderson had no such limitation. And since cancer medicine in many cases is leading the medical revolution toward greater and greater incorporation of genomic data, it was imperative that M. D. Anderson find a way to overcome challenges facing other providers.   Hence the decision to move to in-house development and the commitment to a Services Oriented Architecture. The hospitals executive management embraced the challenge, made the commitment to move up the learning curve to find out what SOA was all about, recognized the benefits, and as a result has fully supported creating an SOA-based ClinicStation from the ground up. 

Exceeded

Because we are a cancer center, things that happen here are likely to be harbingers of things that will happen across the field of medicine generally in the next couple of years, says CIO Vogel. As you get into genomic medicine and personalized medicine, what used to be research will increasingly be part of the clinical process. So the ways we are seeking to link research and clinical data will also become appropriate in other fields of medicine. Similarly, the inpatient and outpatient worlds are becoming part and parcel of the same process and package of care. These developments mean that the IT implications of what we are doing are far broader than just cancer centers.

The potential implications of ClinicStations success also extend far beyond the field of medical care to many other types of businesses. Though organizations talk about using Service Oriented Architecture, most are in initial stages. They are planning, prototyping, or perhaps setting up a single application. At M.D. Anderson, however, ClinicStation is not just an application with SOA. Its the foundation of a service-oriented enterprise. And the interoperability of its IT environment will allow the institution to change with the times, a critical capability for any complex service oriented enterprise.

With the success of its state-of-the-art EMR system, M.D. Anderson has gained widespread attention from counterpart medical institutions, which are eager to discover how they can replicate that success. Invitations to make keynote presentations at national meetings ranging from Bioinformatics Conferences to SOA-focused forums are becoming routine.  By inviting competitors to view the pioneering system, M.D. Anderson is making it possible for other hospitalsand organizations outside of healthcare to learn from its lessons. Ultimately, this is the goal of any prominent teaching institution.

The new ClinicStation has become an instant success with physicians and all members of the healthcare process, who readily embraced an interactive system in which all of a patients real-time information was easily available and could be used within a single presentation environment.   
A key success of ClinicStation over the previous system is that users drove what ClinicStation would do. Instead of radically altering workflow processes, the new system accommodated them. Because the end users controlled whats in the system, adoption has been widespread.  This represents a contrast to so many commercial systems in hospitals, which have often failed or achieved much less than desirable physician adoption rates. Typically, hospitals cant get enough functionality in the systems quickly enough. Another measure of success is the continued demand for more capabilities. 

As many as 8,000 users rely on the system at any given time. ClinicStation has become core to the treatment of the nearly 80,000 patients served by the nations top cancer treatment facility each year. Patients are benefiting from faster treatment and better-informed treatment decisions.  And, as one clinician noted, ClinicStation is simply the way we practice medicine at M. D. Anderson.  But it is essential to keep in mind that the ultimate beneficiaries are not only todays cancer patients but the millions who will be served in the future as research continues working toward a cure for cancer.

ClinicStation is contributing to M.D. Andersons growth. The institution continues to expand dramatically, says Suitor. In every measurenumber of patients seen, clinic visits, surgeries, and revenueit grows every year. While I dont think we can claim ClinicStation is the only cause of that growth, its certainly a significant contributor.