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
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3 4
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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
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254
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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
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