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Dartmouth Hitchcock Medical Center Builds Outpatient Physician Order Entry Application on InterSystems' Caché Post-Relational Database

  • July 01 2004, 1:00am EDT

REVIEWER: Peter Johnson, senior vice president and CIO for Dartmouth Hitchcock Medical Center.

BACKGROUND: Dartmouth Hitchcock Medical Center (DHMC) is an integrated academic medical center in Lebanon, New Hampshire. Serving a patient population of 1.5 million, DHMC includes Mary Hitchcock Memorial Hospital, the Dartmouth-Hitchcock Clinic and Dartmouth Medical School.

PLATFORMS: The DHMC IT infrastructure includes approximately 6,000-7,000 PC clients located in 75 sites across New Hampshire and Vermont. DHMC is running Caché under VMS on HP Alphas in both a clustered and standalone environment. Our main cluster consists of three Alpha Server ES45s with four 68/1000 processors each running under VMS 7.3. The standalone system is an Alpha Server ES45 with (4) 68/1000 processors also running VMS 7.3.

PROBLEM SOLVED: DHMC has consistently focused on leveraging information technology to cut healthcare costs and improve care delivery. Recognizing that having the right information at the point of care means greater efficiency for the clinical care delivery team, DHMC implemented a Clinical Information System (CIS) in 1985. Since that time, what is now called the eCIS has evolved on an ongoing basis to meet new and constantly changing information needs. In 2003, one challenge was the need to reduce the potential for medical errors by adding an ambulatory medication physician order entry (AMPOE) application to the eCIS. The implementation of the AMPOE, which utilizes the Caché post-relational database, has resulted in automatic issuance of tens of thousands of drug/drug interaction and drug allergy warnings. Quantification of the benefits that result from these warnings is still underway. However, DHMC has tracked that approximately 26,000 reminders were issued by the system last year. Based on overall industry trends, it can be estimated that these reminders made it possible to avoid approximately 250 inpatient admissions.

PRODUCT FUNCTIONALITY: Caché is optimized to enable development and deployment of high-performance transaction processing applications. It features a multidimensional data engine where information is stored in sparse multidimensional arrays that eliminate the processing overhead typical of relational databases that use multiple joins. This engine supports the high performance and massive scalability needed by DHMC and enables realistic modeling of the complex data often found in a healthcare enterprise. Caché also supports sophisticated object functionality such as encapsulation, multiple inheritance, polymorphism, embedded objects, references, collections, relationships and BLOBs. These capabilities are key to current and future IT strategies at DHMC as we transition to object-oriented development and increased deployment of applications on the Web.

STRENGTHS: The high performance of Caché is one major strength. Scalability is also a critical success factor because our network is constantly growing.

WEAKNESSES: Overall Caché performs very well for DHMC. However, we have looked at competitor products for handling special purpose environments such as image repositories. Additionally, while Caché does support leading application management tools such as Patrol and Rational Rose, it would be useful if support were offered for more of these tools.

SELECTION CRITERIA: DHMC requirements for the database technology that supports the comprehensive eCIS as well as the AMPOE component included: high performance - very rapid response to information requests from as many as 1,700 concurrent users; RAD environment - staff must respond to growing demands for new applications and enhancements to existing systems; and complex data management - information is in a wide variety of formats including text, CT and ultrasound images, and audio files as well as data. Caché met all of these criteria and has significantly lower administration and management costs than relational databases that are components of the DHMC IT infrastructure.

DELIVERABLES: The eCIS provides more than 40 categories of clinical documentation - in effect, a multimedia electronic medical record. The AMPOE component delivers warnings to physicians on a 24x7 basis. DHMC physicians saw the POE system issue more than 26,000 drug/drug interaction warnings and more than 1,900 severe drug allergy warnings in 2002.

VENDOR SUPPORT: DHMC views InterSystems as a working partner that provides support on a 24x7 basis whenever and wherever it is needed. This was true of the AMPOE implementation as well as multiple application implementations over the course of a successful business relationship that has spanned more than two decades.

DOCUMENTATION: InterSystems provides comprehensive documentation in both print and online formats. DHMC developers find it useful and very easy to understand.

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