Throw away those old index cards

Standards allow applications to share patient info

An unusual thing happened one morning during grand rounds last year at Duke University Medical Center in Durham, NC, — the physicians applauded.

They had just learned of a visual integration standard called User Link. With the standard, users who have been authenticated by one application do not have to sign onto other applications on a workstation. That means they no longer have to remember the various names and passwords to sign into the different applications, information many of the physicians tote around on 3-by-5 cards. When told about User Link, they pulled out the cards from their pockets and began to applaud.

"The integration seems simple and obvious to someone who has not had to log onto multiple applications on one workstation," says Wes Rishel, president of Wes Rishel Consulting in Alameda, CA. People who have worked with the systems, however, know how complicated the process can be. "If you show [the standard] to people who have worked in this environment, they are very enthusiastic about it."

User Link is the latest project of the Clinical Context Object Workgroup (CCOW), of which Rishel is a member. CCOW is a consortium of health care providers and builders of information systems focusing on the collaboration among visual (graphical user interface-based, or GUI) applications on a clinical workstation.

The CCOW project began based on preliminary work from Duke, IDX Systems Corp. in Burlington, VT, and CliniEffect Systems in Durham, NC. "Duke University Medical Center has a long reputation for being successful at integrating applications," Rishel says. "[Integration] is necessary because you really can’t find someone who does everything well. Even if you could, with the way that organizations are being combined, you always end up having to work with existing systems. Therefore, if a hospital buys a practice and the practice already has a system, the physicians have to use their own system and the system of the hospital, too."

Duke recognized that the ubiquity of the Windows operating system provided an opportunity to bring applications together on one workstation, he says. When users switched from one application to another, though, they had to redundantly log in or re-enter the same information.

Duke worked with IDX and CliniEffect on visually integrating the applications, and a demonstration of their efforts caught the attention of a number of health care information systems vendors at a trade show in 1996. These vendors came together as CCOW for the first time in March 1997.

More than 20 vendors and health care providers, such as 3M Health Information Systems in St. Paul, MN, and Hewlett-Packard in Palo Alto, CA, have now announced support for CCOW. (For a list of companies with "CCOW Contributor" status, see below.)

"From [the first meeting] it’s been a case of working out the standards and getting vendors to implement the standards," Rishel explains. "As we go forward, the idea of visually integrating these applications is the overall goal of this group."

CCOW’s principles

Without an easy integration into existing GUI products, however, the goal would not succeed. That’s why CCOW members have established these principles, taken from it’s own white paper, to ensure that its standards would be "robust" and easily adopted:

Widest applicability to applications built on a GUI. The success of a standard depends on its adoption by vendors. The larger interest is not served by building the standard around a language, development package, or piece of special software that will exclude many vendors.

Software component technologies. Software technologies such as ActiveX and CORBA provide the best opportunities for robust, efficient inter-operation, and plug-and-play compatibility. Both technologies are implemented in a number of languages and development environments.

Low application re-engineering costs. An explicit goal is to minimize the work that existing GUI applications would require to become compliant.

Plug-and-play interoperability. Client applications should interoperate with different implementations of the context manager — an automation server that provides the services necessary to implement a context change — without a requirement for adjustments in the programming; the software should be implementable at multiple client sites without reprogramming.

Open participation. Participation in the group is free, but members must commit to the work. The criteria for CCOW Contributor status is consistent attendance at meetings, participation in CCOW demonstration projects, and an intent to adopt CCOW standards.

Standards, not software. CCOW does not sell or give away software that is required for CCOW compliance.

Trade show development schedule. Trade shows offer the ability to coordinate many vendors and receive extra publicity, as well.

CCOW has published one standard, the Patient Link. When applications cooperate using the Patient Link, they track together on the selected patient. Users don’t have to reselect the patient when switching from one application to another. "We have vendors that have modified their software to support that standard," Rishel says.

The finalized versions of the CCOW Patient Link 1.1 have been posted on the Internet. They, along with other information about CCOW, can be found at http://www.mcis.duke.edu/standards/ccow. CCOW also is reviewing the use of Patient Link for Web-based applications.

CCOW is still finalizing its User Link standard. CCOW plans to show the second prototype of User Link at the Healthcare Information and Management Systems Society conference in Atlanta in February.


CCOW Contributors

As of September, 23 health care organizations are listed as having "Clinical Context Object Workgroup (CCOW) Contributor" status.

The organizations are:

- 3M Health Information Systems, St. Paul, MN

- ClinEffect Systems, Durham, NC

- Component Software International, Mason, OH

- Corechange, Boston

- Duke University Health System, Durham, NC

- Healthdyne Information Enterprises, Marietta, GA

- Health Network Venture, Downers Grove, IL

- Health Patterns, LLC, LaGrange, IL

- Health Vision, Santa Rosa, CA

- Hewlett-Packard, Palo Alto, CA

- IDX Systems Corp., Burlington, VT

- Marquette Medical Systems, Milwaukee

- Mayo Foundation, Rochester, MN

- MedicaLogic, Hillsboro, OR

- Mortara Instrument, Milwaukee

- NeoTool Development, LLC, Montrose, CO

- Oacis Healthcare Systems, San Rafael, CA

- Oceania, Redwood City, CA

- OSF HealthCare System, Peoria, IL

- Share Medical Systems Corp., Malvern, PA

- Spacelabs Medical, Redmond, WA

- Sunquest Information Systems, Tucson, AZ

- VHA, Irving, TX