Under Phase I funding CKSI has designed a prototype of protocol software designed to:

• support flexible user definition of protocol triggers, actions, milestones, and allowable variance;
• monitor health care data in a wide range of hardware and software environments;
• alert appropriate providers, managers, or staff members when there are specific guidelines that need to be followed;
• and facilitate outcome and variance review.

• as an add-on to other applications;
• as a separate but concurrent background process that will take control of the screen to issue warnings;
• as an application that works independently to review health care data and ensures that appropriate standards of care have been met.

Internet Growth Has Tremendous Significance for Medical Data Systems.

Within the past two years a major shift in information technology has occurred. This shift was driven by the rapid acceptance and rise in popularity of the world wide web and the possibilities presented by its wide spread use. The Web Browser has become the focal point of the desktop due to its power to integrate voice, e-mail, sound, images, and data into a single window in a platform independent application. This has greatly changed the way in which information could be accessed, distributed, and handled.

The strength in these new technologies lies in their ability to present data in a single window, consistent in look and feel, with platform independence, to a vast and disparate collection of machines and data presentation styles. The user is totally insulated from and unaware of where the information is, how it is being retrieved, and the underlying security which monitors the transactions. The ease, speed and simplicity of the hypertext method of presentation that these new technologies offer has totally transformed how people view computing. Taken together, the power of its data gathering and the friendliness of its presentation provide a method to inform doctors, staff, administrators, and insurance companies of events in advance and force protocol continuity network wide. Since these technologies have an extremely low impact on network architecture and can use existing computing hardware, the hindrances to deployment are minimal, and the users' acceptance and willingness to embrace is great.

The Web Technologies

A Web Browser, such as Netscape, Microsoft Explorer, or Mosaic is an application that is installed on the hard drive of a computer that has functions for displaying text and graphics, resizing, cutting and pasting, printing, and playing sound. The power in the browser is that it allows a developer to focus on what to put in the window without needing to worry about differences in different operating systems or platforms. Any choice that the user selects has hypertext links to information that provide the Web Server the information it needs to locate a particular file or produce information by querying or processing data. These links are invisible to the user, they are commands that start little applications that do the hunting and gathering. So a LAB RESULTS link might trigger a background document hunt that spans 3 mainframes, does security checking, gathers the results, analyzes the results, and triggers a protocol rule with out the user ever knowing any of this happened. The browser presented options, took care of the asking for and accepting of the returned data, and presented the results.

Like a dedicated file server on a local area network, the Web Servers' primary function is to fill requests for files, and send the files back to whoever requested it. Unlike a local area network on which all connections between stations and the file server are maintained permanently, the Web server opens connections called sockets, only when it receives requests for information, and closes them once the information has been sent. Thus a web server can easily serve more users. Unlike a file server the Web Server also understands a scripting language which allows it to execute complex processes which can be used to produce new files. Web Servers are optimized to give rapid responses to user requests. When complex processes have multiple steps, these are run concurrently. Once a user's request is answered the server pays no more attention to that particular user until it gets another request. This environment is optimized for responsiveness and flexibility.

New scripting and application development languages like Java, CGI, and Perl as well as features such as On Line Analytical Processing (OLAP) are being rapidly adapted to the demands of this environment. CGI and Perl allow Web Servers to initiate and complete complex processes at a speed far greater than could be achieved with standard client server software on a dedicated wide area network. Java will allow the response to a request that the Web server sends back to the browser to include an actual executable application. OLAP allows a Web server to automatically convert the results of a query into a hypertext formatted document. As these languages and features mature, the potential of this environment which has only begun to be tapped will be realized.

Advantages of the Web Environment

The Web Server, Web Browser paradigm allows a system to be easily deployed on many different platforms, and frequently updated with absolutely no installation or upgrade problems. All code need only be located or modified on the server. Any screen or Applet changes automatically will be updated by the Web Browsers.

In comparison with more conventional Wide Area Networks using Client-Server systems, Web/Internet environments offer several advantages. On Client-Server systems full applications are actually executing on the client systems, and there is a great deal more traffic going over the network. Performance on the Client-Server application in a WAN environment is very dependent on line speed. Thus dedicated high speed connections often have to be put into place. These can be very expensive, and can also limit the expandability of the network. In the Web/Internet environment lower speed connections are the rule, and everything is structured around keeping traffic minimized. New locations can be added with minimal expense. In this environment the largest issue in improving performance is upgrading the speed or memory of the server. This expense is trivial compared with that of adding high speed connections to diverse locations.

To be truly portable, Client-Server systems have to be set up to run on several different client operating system platforms, such as Windows 3.1, Windows 95, Windows NT, OS-2, Macintosh. While the differences might appear trivial, each will have its own set of unique problems and bugs. It will be necessary to keep close track of versions, memory leaks, all the normal user support needs for custom applications for all these platforms, and to have separate installation programs for all versions. Each environment also has slight differences in the way graphics and sound are supported. All of this is built into the web browser, and in the Web-Internet environment is not a problem to the developer. In the future these features will become more and more important as x-rays, heart cath video results, and other test graphical output are transferred electronically.

In the process of discussing the prototype with other vendors, CKSI encountered MedRecall, an emerging company specializing in the development of Internet environment health care data compilation methods. MedRecall is prototyping a system in which lab results, physicians' comments, patient allergies, on­line prescription submittals, patients' facial portraits and signature, voice conferencing, and chart notes from providers in multiple locations are captured from different sources and compiled for display via a Web Server. Any provider or insurance representative with appropriate security clearance can connect from any location and view all chart notes, test results, etc. for a patient as well as doing key word searches and queries. The opportunity for and benefits of cooperation between our two groups were immediately apparent. With the continued help of MedRecall, CKSI will be able deploy the protocol engine in an intranet environment and have access to tested methods for assembling and compiling data from software and data sets on Data General mainframes, RS6000 and AS400 systems, Novell servers and Oracle and Sybase databases. Our ck_Medical billing package can provide MedRecall a source of "live data" producing real time transaction output. Together, our combined skills will enable us to integrate data from different hardware and software platforms with a dynamic data feedback and analysis mechanism accessible to all users as a natural extension of current Internet based application paradigms.

By developing standard of care and quality monitoring software for an Internet environment we gain the following efficiencies:

1. To be really useful a rules monitoring software should have access to computerized lab data, to chart notes and treatment plans. In an Internet environment there are many more options for setting up this sort of accessibility without incurring inordinate costs.
   
2. Data from all of an organization's locations can be accessed from any site. Critical data can be compiled and centralized.
   
3. Managers will have immediate access to latest information.
   
4. Updates to products and rules can be made easily, and will take effect immediately. It will not be necessary to ship out disks containing changes to all locations.

Integration with systems already developed to maintain on-line lab results and chart notes for an organization will make it possible to take full advantage of the network to improve efficiency. For example a physician may see that he needs a variance from a particular set of guidelines. By clicking on the reason for the variance and adding his own comments, he will automatically generate an e-mail notification to a case manager at another office, who will later be able to examine his notes, review the patient's chart notes, and then either approve the variance or follow up with the physician. Physicians will also have capability to quickly pull up a review of all previous instances in which a particular protocol was triggered, to see how many times rules were followed, and how many times variances were requested or authorized to see how closely circumstances in those cases match his current situation.

By using a Web Server with Java and Netscape, we will be constructing a system that is completely portable. It will run on Internet or intranet connections between clinic and insurance companies or managed care associations, regardless of their distance apart. Data links can be customized at each clinic. Data links are very helpful, and greatly improve efficiency but they are not mandatory. The system can be used with or without data links.

We have potential not only for real time monitoring of protocols, but the possibility of management being notified immediately when there are variances. This adds a great element of flexibility to what would otherwise seem a strict protocol system. By management receiving immediate notification, variances can be requested, and quickly authorized or further discussed. It can be part of the planning process rather than an after the fact questioning or review.