This document describes Catholic Healthcare West's (CHW's) DirectConnect clinical workstation project, an initiative started in early 2007 as an effort to provide role-based, integrated access to clinical data. It should be of interest to CIOs, CMIOs and CTOs who want to rationalize the clinical workflow.

• CHW has approximately 130 clinical systems that can be instantiated natively and in context (see Note 1) from within the DirectConnect clinical workstation.
• Meditech, Eclipsys, and CareData viewers have been created for Web portal access, which can also be launched from within DirectConnect.
• The DirectConnect workstation uses commercial off-the-shelf (COTS) products such as WebSphere, Novell and Carefx to design and implement the clinical workstation and provide single sign-on, workflow and context (user, patient, encounter) management functionality.

• When developing a clinical workstation or portal, look for integration and interoperability tools that are standards-based and that can leverage the existing IT infrastructure and application portfolio as noninvasively as possible.
• As a patient safety measure, use context management to synchronize user, patient and encounter information between two or more independent desktop or Web-based applications.
• Deploy single sign-on to simplify and streamline user access, and provide stronger authentication for remote access.

CHW's DirectConnect clinical workstation is rapidly becoming a vital extension to its clinical system environment. Currently, it is has been implemented in 14 of CHW's 42 hospital facilities. It provides the clinician with streamlined, role-based, single sign-on access to multiple desktop and browser-based applications that are set forth in individual user profiles and instantiated within the workstation. User, patient and encounter context is maintained once the clinician has authenticated to the workstation. This helps reduce patient selection errors and promotes patient safety. Using a federated, service-oriented approach, DirectConnect aggregates data in real time from its various constituent applications and displays this information in the form of read-only viewers. Clinicians are able to quickly access patient lists and drill down to vital signs, laboratory results, radiology studies and medication lists. Enterprise applications like the Meditech (computerized patient record) and Emageon (picture archiving and communication system — PACS) can also be invoked natively and in context within the workstation when data needs to be entered or maintained or when specific application functionality needs to be accessed.

CHW's reliance on the paper chart has dropped dramatically since the introduction of the DirectConnect clinical workstation. All the most vital patient information that clinicians require to deliver care is presented via DirectConnect — either as read-only application viewers or as part of the native application that owns, manipulates and stores it. The DirectConnect Meditech viewer, a component of the clinical workstation, has simplified access to this critical clinical system through an intuitive Web-based presentation. Integrated single sign-on and context management ensures that the user has been authenticated to all clinical workstation desktop and Web-based applications and that these applications have been synchronized to the selected patient. Most importantly, DirectConnect enables a much improved, paper-free clinical workflow that connects clinicians to the information necessary to deliver care. For the physician, this means increased productivity and convenience, a more-efficient clinical workflow, and improved patient care.

Founded in 1986, CHW is a large, faith-based, integrated delivery system composed of some 42 acute care hospitals, with more than 7,000 licensed beds located in Arizona, Nevada and California. CHW has approximately 50,000 employees and more than 8,500 physicians. CHW also provides home health, hospice and infusion services, as well as a host of health and wellness and chronic disease management programs. CHW is the eighth largest hospital system in the nation and the largest not-for-profit hospital provider in California.

Like most care delivery organizations, CHW wanted to enable its physicians to provide the best care possible and to leverage IT assets to that end. CHW realized that, to deliver on its stated vision of providing high-quality, affordable health services, it would have to rationalize the clinical workflow and reduce the number of disparate clinical systems that physicians and clinicians have to access and navigate to retrieve patient information. CHW had to reduce the number login/password pairs that clinicians had to manage and provide better context for the information returned by a variety of disparate clinical applications. A consolidated view of patient information was at the core of its approach, along with the concepts of expedited access and data federation.

CHW began first by outlining the functionality it wanted in its clinical workstation, rather than focusing on the technologies required to implement it. This effort took the form of a detailed set of use cases referred to as a clinical workflow assessment. These requirements were developed in close collaboration with the CHW clinical staff, with IT providing the necessary project management and oversight. This effort resulted in a preliminary high-level design and system architecture. To keep this initiative as affordable as possible and within financial constraints, CHW endeavored to leverage as much of its existing IT infrastructure and application portfolio as possible. This meant it would have to rely heavily on front-end and back-end integration and interoperability standards and technologies. Armed with its functional requirements, preliminary design and architecture, CHW called on Carefx — a healthcare system integrator and identity management vendor — to create a detailed project plan that would bring together the necessary specifications, tools, technologies, applications, vendors and stakeholders to form a clinical workstation solution.

CHW had outsourced a large portion of its IT department to Perot Systems in 2001 and along the way standardized on a number of computing and application platforms and standards. For example, Novell is the enterprise single sign-on vendor as well as the enterprise directory, Courion provides user provisioning, VMware is the server virtualization vendor, and IBM WebSphere serves as the portal platform. Carefx's Fusion and Desktop Process Management (DPM) products serve as the framework for the clinical workstation. The Fusion and DPM products, along with the data aggregation platform, application extenders, context management software, and workflow capabilities, were integrated through services and application programming interfaces (APIs) with the Novell and IBM platforms and the various clinical applications to form CHW's DirectConnect clinical workstation.

With 14 of the 42 hospitals using DirectConnect, CHW is well on the way to achieving its vision. DirectConnect currently aggregates patient data from multiple, disparate clinical systems and provides both desktop and portal (viewer) role-based access. DirectConnect's data access layer is service-oriented and uses Web services and various APIs to collect and aggregate data from CHW systems, such as Meditech, Cerner, Eclipsys, CareData, Emageon and Logicare, among others. Currently, DirectConnect has been deployed only within CHW's inpatient settings — acute care, patient rooms and nursing station kiosks — in a tightly controlled, locked-down mode for security purposes. It provides the clinician with navigational or data context — or the ability to move among multiple workstation applications and viewers and be assured that the patient information has been properly synchronized. Where shared services are required — in a ward, in a common area or at a physician station — DirectConnect is implemented using the DPM. Where individual remote access is required (for example, at an affiliated physician office), DirectConnect is deployed as a browser-based viewer. In the long term, DirectConnect should evolve to an even more integrated composite application where the user no longer has to invoke the native applications for data entry or update activity, but rather, can seamlessly integrate with services and APIs provided by these desktop and Web-based applications.

Physicians and nurses at CHW have reported significant time savings as a result of using the DirectConnect clinical workstation interface. Hospitalists have reported that they can save up to two hours daily per clinician due to the efficient and intuitive access to patient information that DirectConnect provides (see Figure 1). This has also enabled hospitalists to spend more time with their patients and focus on delivering care. DirectConnect has become an important component of CHW's physician satisfaction initiative. Eric Leader, CHW's chief technology officer, is one of the executive sponsors of DirectConnect. Under his guidance and leadership, the DirectConnect project has remained focused on streamlining access to clinical information through the aggregation of patient data and context integration across these multiple systems. Mr. Leader reports that the overall project is ahead of schedule, and he expects DirectConnect to be implemented in the remaining CHW hospitals by the end of 2008.

• A rigorous and detailed clinical workflow assessment was necessary to establish the foundational use cases for the CHW clinical workstation.
• Physician and nursing input to the foundational use-case scenarios ensured that workflow and data presentation were accurate, complete and relevant, and their involvement was critical to clinician acceptance and the timely deployment of the system.
• The integration vendor must have the tools, technologies and project management skills to integrate clinical data, leverage existing IT infrastructure, and integrate identity and access management (IAM) requirements.

• Hospital clinical and financial leadership must be fully engaged, or project acceptance and deployment timelines will suffer.
• Workstation functionality should be deployed in increments large enough to form a coherent and consistent clinical environment that services the most important clinical workflows.
• The performance and availability of the integrated clinical workstation must match those of the underlying native applications, and in most cases, ease of use must be considerably better.