Web-Based Medical RecordsDesign and Implementation at

Columbia-Presbyterian Medical Center

James J. Cimino, M.D.

Department of Medical Informatics

Columbia University

CPMC in 1988 - preTCP/IP

IBM MainframeData

Repository

DataMonitor

VocabularyServer

ResultsReview

CliniciansAncillary Systems

Data Monitor - Input and Alerts

• Stores all data in repository

• Checks data for triggers

• Executes Medical Logic Modules

• Stores alerts in repository

Data Repository

• Row-oriented relational database (DB2)

• Event-oriented

• Flexible and extensible

• Clinical data coded with MED

• Multiple time stamps

CPMC in 1991 - TCP/IP

Minicomputer

IBM Mainframe

DataMonitor

VocabularyServer

CliniciansAncillary Systems

UploadEngine Vocabulary

Server

Minicomputer

DataRepository

Intranet

ClinicalApplication Vocabulary

Server

ResultsReview

Clinical Database Server - Output

• Dynamic queries (SQL)

• Canned queries– Time span– Last "n" results

• Class-based retrievals ("get all positive culture results")

Medical Entities Dictionary (MED)

• 56,000 medical concepts

• 82,000 synonyms

• Multiple hierarchy (72,000 links)

• Semantic network (43,000 links)

MED Semantic Network

CalciumPreparations

Calcium IntravascularCalcium Tests

Abnormalitiesof Calcium

Hypercalcemia HypocalcemiaSerum Calcium Plasma Calcium

Tests FindingsChemicalsMedications

MED Server

• Lexical searching

• Concept attributes

• Classes

• Ancestors

CPMC in 1994 - WWW

CliniciansKnowledge Resources

Minicomputer

VocabularyServer

IBM Mainframe

DataMonitor

Intranet

Internet WebServer

DataRepository

Internet

Web Server

• Clinical database server queries

• Vocabulary server queries– Class queries– Translation

• HTML document generation

• Applets

• Web links

Web-Based EMR

Clinicians

Minicomputer

VocabularyServer

IBM Mainframe

DataMonitor

Intranet

WebServer

DataRepository

CPMC’s Web EMRs

• Elpis - single patient view

• PolyMed - service view

• WebCIS - multiple views

• PatCIS - for patients

Web EMR Features

• Frame-based interface

• Summary reporting

• Graphical displays

• Multimedia displays

• Cross-patient displays

• Order entry

• Integration of on-line resources

• Security and confidentiality

Screen Shots of WebCIS

PatCIS

• Data review

• Data entry

• Education

• Advice

• Infobuttons

PatCIS Architectural Features

• Frame-based user interface

• Buttons and "sub-buttons"

• Single central CGI– security– usage logs

• JavaScript functions to support application integration

Data Entry

Review

Advice

Education

Comments

Help

Logout

JavaScript

Vital Signs Blood Sugar

Data Entry

patcis.cgi

Web ServerWeb Browser

SessionRegistry

Re-enterPassword

UsageLog

Internet

JavaScript

Link

1

2

3 4

5

6

789

10

CGI

CGI

11

PatCIS Architecture

Advantages of PatCIS Design

• "Light" user interface• Handles security for applications

– identification– authentication– authorization– logout– timeout

• Handles logging functions– tracks usage– records accesses to clinical database

• Maintains consistent look & feel

Screen Shots of PatCIS

Integration with On-Line Resources

Clinicians

Knowledge Resources

Minicomputer

VocabularyServer

Intranet

Internet WebServer

Internet

Integration through Terminology

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

Querying

Presentation

UnderstandInformation

Needs

AutomatedTranslation

1

254

6

3

7

Infobuttons

DXplain

Medline

CholesterolGuideline

DietaryInteractions

PDR

Micromedex

Clinical InfoSystem

Webpath

CHORUS

Radiol Museumof South Bank

LaboratoryTest Results

MedicationOrders

X-rayReports

Screen Shots of Infobuttons

Security and Confidentiality

• User logon name and password

• Encryption (SSL)

• Logon screen ID (single use)

• Session screen ID (expires)

• Database access log

Current Challenges

• Security

• User ID management

• No control over client machines

• Application development

• Navigation of hypertext

• Resource integration

• Evaluation

Ingredients for Success

• Powerful, flexible back end– Repository– MED

• HTML and HTTP

• Web resources

• People