"Just like Heathrow " is how Barrie Winnard, information management and technology manager at Moorfields describes the comings and goings on a typical day at the renowned London eye hospital. As a national centre for ophthalmic care, the hospital`s main challenge is not so much pressure on beds, but managing the high volume of outpatients - usually over 1,000 coming through the door every day from all over the country.
This is just one of many things about Moorfields Eye Hospital which sets it apart from the ordinary. As well as being a national centre of specialist medical excellence, it is also way ahead of the NHS game in the IT stakes. Although government imperatives say that electronic patient records (EPR) should have reached level three by 2005, Moorfields is currently aiming to achieve level six by that time.
Mr. Winnard puts this achievement down to his department`s policy of developing partnerships with a small number of software suppliers and working with them to redevelop existing systems. This way of working has come about because of Moorfields` unique character - a single speciality centre with an emphasis on short duration stay.
He explains that this means off-the-shelf software have never quite fitted at Moorfields. To overcome this, the hospital has turned to consultancies and suppliers to provide bespoke packages that match precisely with its business processes. "Not the norm in the NHS," he explains, "but it works for us."
This policy is now paying dividends way beyond the usual advantages of using tailored systems. For example, the hospital is currently totally upgrading its patient administration system (PAS), which holds all patient demographics such as address, date of birth, GP, admission details and so on. Working with healthcare specialist software supplier Stalis it has opted to redevelop its Mumps-based system to one run on Cach'e that offers the speed and performance critical to the hospital, plus completely open technology.
InterSystems describes Cach'e as "post-relational" to distinguish it from old-fashioned relational databases that force data into a simplistic two-dimensional model. Cach'e stores data in multi-dimensional structures that enable high-speed performance and massive scalability - both essential for this application.
For Moorfields, the benefits of redevelopment have been considerable. There has been no need to go through the lengthy and extremely expensive procurement process. Considering that over 500 devices had to be reconfigured over 12 sites, the change of the hardware from mainframe to server technology was relatively smooth and controlled. Users report far superior performance. Also, because Cach'e has allowed the migration from a Sequent mainframe to a Compaq NT server, real savings of around lb30,000 a year have been shown.
"Many of my colleagues have assumed that any development will cost them money," says Mr. Winnard. Maybe Moorfields is unusual, but not only is this project enabling us to provide better care to our patients, it is also providing us with both real and potential savings."
"Changing PAS could have been such bad news"
"As any hospital will tell you, changing your PAS is a major upheaval," says Mr Winnard. "If you are talking about completely replacing your main system and starting all over again, not only is there the whole expensive and time-consuming procurement process, but there`s also the management of change within the hospital. It affects virtually every single person working there."
Moorfield`s original PAS went back to the early 1980s, and although it had served the hospital well, with all the changes in the health service it was decided that something easier to use was needed. There was also the problem of an ageing mainframe which badly needed replacing.
The hospital began to consider investing in a Unix mainframe and looking at different relational databases such as Oracle, Ingres, Sybase or Informix - "none of which were ideal and could prove to be extremely expensive," according to Mr. Winnard.
By 1997 the hospital decided that something dramatic was needed and wrote a whole new IT strategy. It was at this stage that Moorfields started discussing the issue with Stalis, a small Oxfordshire based consultancy highly-experienced in the provision of information and IT services to the healthcare market.
John Evans managing director of Stalis takes up the story: "It was around this time that Cach'e appeared and we could see immediately that it could provide us with the most cost-effective way forward. Basically Cach'e made it possible to move forward on the redevelopment route."
Not only did this mean there was no need to wait the usual year - 18 months that procurement typically takes, there was also another bonus. As Cach'e can run on smaller servers, plans to buy the expensive Unix hardware could be shelved. Instead they settled for a high end Compaq NT mirrored server, saving the hospital around lb180,000.
However, although it looked as though Cach'e could provide the key to cost-effective progress, Moorfields and Stalis still needed some final convincing. As Mr. Winnard explains: "We could see the advantages but we were very concerned about performance, particularly as previous experiences with purely relational databases showed they perform poorly in transaction based applications.
"We were particularly concerned as we were going away from mainframe back down to server technology and we needed reassurances from InterSystems as to whether Cach'e would work with our large number of users and with the number of transactions we were making."
Their worries were unfounded. When Cach'e was put onto the new Compaq server it more than proved itself. "The performance is excellent; name searches on a database of just under one million names and over 200 concurrent users are instant."
In such a busy hospital as Moorfields, an unresponsive computer system would prove disastrous: "We needed to provide software which precisely met the needs of those clerks dealing with a queue of patients," says Mr. Evans.
"Open technology has made life easier" So far, the team has redeveloped the patient master index, is starting on the inpatients system and will then progress on to outpatients. It is also working on a new GUI front end, ensuring that not only does the user get an instant response, but also that they find the system intuitive and easy to learn. Around one half of Moorfields` 900 staff need to be able to use the system, not all of them, by any means, IT-trained.
One of the main driving forces of changing the system at Moorfields had been the complete overhaul of how the NHS is run in the mid 1990s including the introduction of a patient charter with its restrictions on waiting lists and the creation of purchaser/provider relationships with health authorities. This means that another priority for the development team has been to work a solution into the PAS that will allow staff to make the decision when to admit a patient.
When a doctor decides a patient needs to be admitted or be booked for treatment, the system will be able to check whether the service level agreement with the appropriate health authority has the capacity. It will also show the optimum appointment or admission time to fit with these requirements. This will then be balanced with clinical priorities -whether or not the case is urgent.
The hospital has been doing a lot of work on planning its service level agreements with the health authorities using its services, building sophisticated models to help plan, manage and monitor these more efficiently. "The whole system is in development, but through modelling the hospital has been able to better predict its waiting list and wait times over the coming year," explains Mr Evans.
This he says has been greatly helped by Cach'e`s open technology which makes it easier to export the data needed for the modelling system.
This open technology also means that linking the PAS to a clinical system is proving easy to achieve. "Because of Cach'e our links are getting far more sophisticated," says Mr. Winnard. "In the past they were just one way, we were just taking patient demographics across. Now that latest link we`re discussing is for booking patients from another system - which is exciting."
Both Stalis and Moorfields have no doubts that without Cach'e`s open technology they would have been unable to get this far. "Cach'e has made our lives a lot easier," says Mr. Winnard.
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