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Title and Description
HUG: University Hospitals of Geneva – integrated network for sharing patient-specific data
Reviewed/ candidate case
Quality reviewed case
Short description
The University Hospitals of Geneva (HUG) is a consortium of public and teaching hospitals in the Geneva region, offering primary, secondary, tertiary and ambulatory care. Its widely used clinical information system is a component-based, message-oriented solution, featuring advanced tasks such as ePrescription and clinical pathways.
Objectives and purpose
The strategy leading the development of the clinical information system CIS has been founded on several pillars: Objectives * improve safety and quality of care first; * help care providers first; * tight integration in the hospital information system (HIS); * at the heart of the HIS; * must be able to integrate third part solutions; * must be useful for all stakeholders, including logistics of care and hospital management.
Detailed description
The HUG is consortium of 7 public and teaching hospitals in four campuses and more than 30 ambulatory facilities in the state of Geneva. HUG manages over 48,000 admissions and 800,000 outpatient visits each year, with a base of more than 2000 beds and over 10’000 employees and 7000 care professionals, with an annual budget of nearly 1.4bn CHF. HUG covers the whole spectrum of outpatients and primary, secondary and tertiary inpatients care, including long-term rehabilitation and psychiatry. Since 2000, a unified and shared patient-centred clinical information system (CIS) is used in the complete HUG running on more than 7,000 PCs. More than 25,000 records are open every day, 7 days a week, around the clock with never less than 500 records accessed each hour. The system serves all care providers, including physicians, nurses, medical secretaries, social care providers, physiotherapists, nutritionists, music therapists, etc. The CIS is mainly an in-house development. It is component-based with a message oriented middleware distributed system. Several components or clinical systems, such as the PACS, are industrial solutions that have been integrated into the CIS. Only components not available on the market have been built in-house, using JAVA. Numerous interfaces, extracting data from different databases, are been built in order to allow customised viewing of data according to providers’ needs and wants. The CIS is patient- and user-centred in its input and output elements, even though distributed behind the interface scenes. Queries are managed according to access rights and interfaces based on the clinical role of the person performing the query, and are always restricted to a specific patient with tight and constraint rules for privacy protection. All accesses are authenticated with a smartcard. The system has links with private laboratories in order to receive lab results from outside the consortium. The records in the system, including lab results, reports, prescription and images, can be sent electronically to external addressees, such as private hospitals and GP practices using a secured and authenticated network. Integration with other systems is planned. The Clinical Information System (CIS) comprises administrative information, unified clinical documentation, order entry for all orders (such as laboratory, drugs, radiology, nursing care, referrals, etc..), imaging (DICOM), laboratory, for the most important aspects. Patient identification and trajectory, admission, discharge, and transfer information, are built according to the HL7 RIM model. As of end of 2008, clinical and nursing documentation are stored as more than 15 million documents and 150 million structured facts, 70'000 new images are stored daily, more than 20'000 order entry are processed every day. Hence, the CPR is used for many other purposes than care, such as admission administration, billing, resource management, epidemiology, and clinical research.
The budget of the IT department of HUG is less than 3% of the total hospitals budget of CHF 1.4bn. IT investment plans are presented as part of the general investment proposals to the canton parliament in four years cycles. The canton parliament is responsible for deciding on public investments of more than CHF 1mill. The budget for of the department of medical informatics at HUG is covered to 50% by the extra funds coming from the government, and to 50% by HUG’s internal sources. The medium run plan is to exploit financial savings or extra income by using the system as a financing source.
Interoperability and standards
The system is architecturally built in four very layers: 1) The visual components layer is the only one providing user interfaces. Components at this level use all underneath components to get data, logic, behaviour, etc. in order to build specific and pertinent views for profiles and specific users. They provide HTML and Adobe Flash interfaces. 2) The business components provide specific business logic. Some of them allow the physician order entry for radiology, or the clinical data management for nurses, or decision-support. They are written using Java and communicate with XML messages. 3) The foundation components are the major shared foundation of the CIS with functions such as security, workflow, scheduling, notification, etc. They are written in Java or are industrial components. They communicate with XML. 4) The database layer. Each component of the 2nd and 3rd layers has their own data sources, which can be accessed by no other component directly. If any other component needs these data, it has to use the services provided by the owner component. An important feature of this architecture is that interoperability is a fundamental requirement. As all components are completely independent and can only communicate through standardised http/XML services or standardised XML messages, a common framework of protocols and semantic formalisations has to be used. Most of this has been achieved using existing standards whenever possible.
Timescale
Start of planning
1998
1st milestone
1999/2000: Start-up of work on the information infrastructure.
2nd milestone
2001-2003: first major increase in uptake, following large scale deployment.
3rd milestone
2007: cumulative break-even from a socio-economic perspective.
Start of routine operation
2000
Evaluation
Ongoing
Characteristic of the application
Country
Switzerland
Part in the healthcare chain
Diagnosis
Therapy
Rehabilitation
Follow-up / long-term care
Facilities and logistics
Research
Level of Implementation
Regional
Technology
Bespoke/ locally build solutions
Details on Technology
The foundations for the information systems’ architecture is based on using the JAVA language, internet browser technologies as thin client and distributed application servers. This has been organised along two main axes: 2) Transversality - the need for abolishing the frontier between clinical and administrative visions of the information system, towards an integrated environment, implies the transversal use of many functional foundations, such as access rights management, traceability, workflow, resources management, scheduling, etc. 3) Longitudinality - the necessity to be able to follow the citizen’s journey through a complex and fragmented health and healthcare system implies the development of a longitudinal view of the computerised patient record, and the convergence and integrability of the hospital within a community healthcare system. The clinical middleware has been organised on some important strategic decisions: * distributed open components * independent and specific visual components * events and message-based interactions * business oriented web services * strong ability to tightly integrate third-party and commercial solutions.
Results
Outcomes
More than 25,000 records are open every day, 7 days a week, around the clock with never less than 500 records accessed each hour. The system serves 7000 care providers, including physicians, nurses, medical secretaries, social care providers, physiotherapists, nutritionists, music therapists, etc. In 2007, cumulative break-even from a socio-economic perspective was achieved at some CHF 60mill. By 2009, the value of annual benefits is expected to be more than twice the value of annual costs. Most costs and benefits are related to HUG as an organisation.
Wider impact
Some negative and positive impact is also observed for physicians and nurses. However, initial inconveniences have been overcome. The main impact outside the scope of the organisation is the improved quality of care, including patient safety, stemming from better informed decisions by care providers and various decision support features such as alerts and clinical pathways.
Results expected?
The quality of care and access to services improvements were expected. Unexpected were some patterns of uptake, such as rapid increases related to new recruitment from the university’s medical faculty.
Success factors
* People: A combination of high-level, visionary people at both, the political, the clinical, the technical and the operational level, supported by people who excel in health informatics. * Changes in working practices: facilitated by better data access and data sharing. * Engagement of users: more than consultation. * Implementation strategy: avoiding too many changes at one time; no planned withdrawals of functionalities before roll-out.
Failure factors
* Older people took longer to accept and adapt, as some of them needed to learn some computer basics first. Younger people were more likely to be comfortable with computers.
* Doctors and nurses at HUG acknowledge that they do not use all of the functionalities of the CIS and need to learn more about what the system can do and how.
* One possible risk factor might be over-reliance on the CIS.
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