Prescription for success: at Hackensack University Medical Center, an unlikely branch of...

When someone mentions technology that is improving medical

care and has the potential to save lives, most people think of a new diagnostic test or a state-of-the-art surgical technique. At facilities like Hackensack University Medical Center (HUMC) in New Jersey, however, an unlikely branch of technology--IT--is playing a major role in helping doctors and nurses provide better patient care.

Specifically, real-time, wireless access to patient information and clinical applications, such as computerized physician order entry (CPOE) deployed across the medical center campus, is allowing HUMC's peripatetic physicians, nurses and other staff members to improve decision-making, speed treatment and help ensure patient safety--with the desirable side effect of cost savings.

The move to computerized clinical information systems (CIS), which encompass electronic medical records (EMR), CPOE, medical documentation, orders/results and other processes, is a major healthcare topic today. The goal is to have comprehensive, up-to-date medical data for each patient available electronically at the bedside, instead of stuffed into a manila folder.

Some healthcare organizations are adopting CPOE, which enables physicians to input orders for medications, diagnostic tests and treatments directly into the computer instead of handwriting them, to improve accuracy and reduce medication errors. Converting from a paper-based to a computerized system, however, is a complex project--with many challenges and, potentially, high costs.

HUMC is a major research and teaching hospital and New Jersey's largest provider of inpatient and outpatient services. With technological innovation playing a key role in the healthcare provider's high-quality care, HUMC implemented a CIS that would ultimately deliver EMRs, CPOE and other capabilities. Part of this multiphase project was the deployment of several modules of IDX LastWord, a clinical software solution, over a wireless LAN using access infrastructure software from Citrix Systems.

"Our goal is to provide real-time access at the point of care to the complete patient record for our caregivers," says Gerard Burns, M.D., director of medical informatics at HUMC and a member of the medical staff. "The ability to view and input all types of information immediately, using one centralized computer system, allows physicians, nurses and other staff to make informed decisions and enable the best outcomes for our patients."

WIRELESS CONCERNS ADDRESSED

HUMC sought the best strategy for delivering the CIS system and other applications at the point of care to its highly mobile physicians, who needed access within the hospital campus and at remote locations, and to three shifts of nurses, who needed access at the patient's bedside. To Benjamin Bordonaro, HUMC's director of applications development and support, wireless access offered the mobility these caregivers required.

Bordonaro, however, had security, performance, administration and cost concerns about implementing a wireless system. Specifically, he worried that installing applications on wireless devices would put confidential patient information at risk in case a machine was lost or stolen, and that tracking down each device for application updates and maintenance would overtax his IT team.

There was additional concern around the slow performance of data-intensive applications over a wireless LAN. In addition, Bordonaro wanted to leverage as much of the current HUMC infrastructure as possible to keep expenditures down.

He found a solution by turning to HUMe's existing implementation of Citrix access infrastructure software, which was providing employees on a variety of devices with wired access to centralized applications. Citrix MetaFrame Presentation Server offered the ability to extend this implementation to support wireless access, without the need to rewrite applications.

Citrix access infrastructure separates an application's logic from its user interface, centralizing installation, processing, administration and deployment on the server or server farm. Users access the application on any device, over any network connection, sending keystrokes and mouse dicks to the server and receiving screen refreshes. The access infrastructure offers greater IT efficiency from centralized application rollouts, updates and support, high application performance over bandwidth-constrained networks and inherent data security by housing applications on the server rather than each device.

To further enhance the planned wireless-access project, Bordonaro decided to upgrade to Citrix MetaFrame XP Presentation Server software. This version of the product offers application performance and Web-enabling capabilities, in addition to more robust security and administration, to address wired and wireless application-access challenges.

THE NETWORK IMPLEMENTATION

To accelerate the wireless access project, Bordonaro and his team had Citrix's consulting group, Citrix Consulting Services (CCS) provide an analysis of the existing MetaFrame 1.8 architecture and assist in the design and configuration of the MetaFrame Presentation Server implementation. CCS also performed a subset of application testing to ensure the new configuration would work in the fast-paced healthcare environment.

HUMC implemented Citrix MetaFrameXP Presentation Server software with Microsoft Windows 2000 Server software, running on approximately 30 HP ProLiant servers. In order to meet full redundancy requirements for performance and scalability; the HP servers were split between HUMC's two data centers and connected to the HUMC network backbone via load-balanced network connections.

"Every application and Citrix server has a backup in the event of an outage of disaster," says Bordonaro, "providing 24/7/365 access to critical clinical, financial and operational applications." The server design specification allows the application environment to run on one data center in the event of an interruption to the other.

Published applications are delivered over a Cisco wireless LAN to cart-mounted wireless Fujitsu Stylistic tablets in the patient care units, and to wireless Fujitsu LifeBook sub-notebooks carried by physicians across the hospital campus. Doctors who warn to access applications from any of the medical center's several dozen remote physician offices and specialty services centers, or from home, can connect over the Web.

Like any major IT project, this one ran into a few problems. The wireless network, initially installed in separate components by building or floor, experienced coverage gaps as users roamed from point to point. Deploying the entire wireless infrastructure on a single virtual LAN (VLAN) solved this problem, thus minimizing disconnects while physicians roam frequently between nursing stations and building floors.

The migration to MetaFramc XP Presentation Server caused some existing applications to behave differently. Testing and troubleshooting corrected problems that resulted when the upgraded software allowed publishing of individual applications instead of the entire desktop. In addition, certain applications did not perform properly when installed on the same Citrix server with other applications. For that reason, Bordonaro had to re architect and reconfigure the server farm, purchase some new servers and separate these applications from each other, adding some unexpected costs to the project.

PHASED APPROACH FOR WI-FI

Currently, HUMC is 100% Wi-Fi ready and is rolling out wireless tablets and sub-notebooks in stages--unit by unit, floor by floor. This phased approach was a decision based primarily on the extensive education, training, support and acclimatization required to move from a paper-based to a wireless information system.

The CPOE system is also being implemented using a phased approach. Functionality is increasing, as nurses, using the nursing documentation and Electronic Medication Administration records modules, are able to electronically input patient vital signs, assessments and other clinical information, as well as document the medications they administer and any related problems. Additionally, physicians are accessing the CPOE application to input orders for diagnostic tests, medications, lab work or treatments such as physical therapy.

"We chose specific patient care units based upon patient type and volume, physician specialty and staffing," says Burns. "For the medical staff, we made CPOE optional. We provided physician and staff training, plus all the functionality we could, such as dictated reports within the CIS and electronic signature capability."

Although still being rolled out, the benefits of HUMC's wireless access project are already being felt on both the clinical and IT sides of the organization. "Taken as a whole, these benefits, which range from streamlined medical processes and better-informed clinical staff to greater IT efficiency and cost savings, promise to help the medical center enhance patient care and safety, attract and retain staff, and sustain its reputation as a leading technologically progressive institution," says Lex Ferrauiola, vice president, information technology, and chief information officer.

The complex process of caring for an ill or injured person is reliant on an abundance of information, including but not limited to the patient's history and current diagnosis, test and procedure results, medications and vital signs. To provide the most effective care, each professional on the team needs to be aware of all this information. That is a tall order when the patient's condition is changing daily, if not hourly, and there are multiple physicians, nurses and staff providing care around the clock.

"We have begun the rollout of wireless notebooks for use during multidisciplinary rounds," explains Burns. "Because all the information about a patient is instantly available via the wireless notebook, we can bring everyone up to speed, answer questions and decide on next steps."

Another enhancement in care that wireless information access provides is shorter turnaround times for tests and procedures. "When everything is paper-based, the time required to order, complete and report a test can be as long as 36 hours," says Burns.

In contrast, with CPOE, "Sometimes the doctor hasn't even left the unit when the order goes through and the nursing staff is notified about transport of the patient down for the test or procedure," he adds. Faster turnaround means that the next phase of care can be planned and implemented more quickly. It also contributes to greater patient satisfaction.

Centralized management functions in the Citrix access infrastructure also solved a major potential headache-finding and updating the wireless devices. "With this solution, we don't care where the doctors have taken their notebooks, because all the application administration-including installation and upgrades is done on the server," says Bordonaro. "If the applications were installed locally, we would constantly be trying to track down the devices all over the campus and in doctors' offices, cars and homes."

In addition, the session-shadowing capability of MetaFrame Presentation Server lets IT staff remotely support and train users on the CIS modules. This centralized-management capability translates into substantial IT cost savings because fewer staff is needed to support a growing user base.

The server-centric model also helps ensure high application performance over the wireless network. Only minimal data travels between the server and client, allowing HUMC to optimize the capability of its wireless LAN.

As a healthcare provider, HUMC must comply with the stringent requirements of the Healthcare Information Portability & Accountability Act, especially the security and privacy of patient information. Because applications are server-based, data is simply viewed--not stored--on the wireless devices. So, if a tablet or notebook is lost or stolen, confidential medical information is not put at risk.

The implementation also supports continuous operations, which are essential to a medical center. The advanced load-management features are used to configure servers across two fully redundant data centers, which ensure continuous access to applications even in the event of an interruption. In the case of a power outage, the servers are connected to backup generators to permit continued availability of computerized systems.

"Once our nurses learn how to use the wireless tablets and applications, they can't imagine how they survived without them," says Burns. "It really makes nursing workflow more efficient."

Equally important, as healthcare becomes increasingly consumer-driven, the latest technology may be a key factor on selecting a doctor or medical center. "As consumers become more educated and discriminating about medical care, they will begin to demand measures like CPOE and electronic documentation that ensure safer, higher-quality care," Burns offers. "Taking the lead in information technology makes us a better institution for our patients."

About Citrex Systems

Citrix Systems is a provider of infrastructure-access solutions that offer secure access for enterprises and individuals. Based in Fort Lauderdale, Fla., Citrix has 2,000 employees in 22 countries and more than 7,000 channel and alliance partners worldwide. In fiscal 2003, Citrix posted net revenues of $588.7 million.

Mark Templeton, Citrix president and CEO. joined the company in 1995 and assumed his current role in 1999. Templeton and his executive team have grown Citrix from a one-product company to a global firm with operations across Europe, Latin America and Asia-Pacific. Most recently, Templeton led the acquisition of Expertcity, a leader in Web-based access services, to help accelerate Citrix's growth in the access-infrastructure market.

Prior to Citrix, Templeton amassed more than a dozen years of management experience at the UB networks division of Tandem Computer, Keyfile Corp. and LANSystems. He earned an MBA from the University of Virginia's Darden School, and graduated from North Carolina State University with a BA in product design.

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