Like its civilian counterpart, military medicine has undergone fantastic changes in recent years.

The changes don’t merely reflect medical advances. They also reflect the role which non-medical technology now plays in ensuring that information critical to sound patient care is where it needs to be, when it needs to be there.

Technology also can ensure that patient information is accessible to medical professionals who need to review or update it, after which the data are made available to everyone on the medical team with a need to know.

--- LinkWorks User

"The days when we provided soup-to-nuts patient services ourselves, without offering outside consultations, are long gone," commented a physician at Wilford Hall Medical Center Hospital, San Antonio, Texas. "Like every other medical facility, Wilford Hall needs to ensure that its patients get the best care available, and we have to provide it at a price that’s financially competitive with civilian HMOs."

For that goal to be achieved, disparate specialists involved in a patient’s diagnosis and treatment must be able to quickly and easily access and update detailed patient information and the patient’s full medical history. When care-givers require access to information which is stored in part in mainframe systems, in part in office systems, and in part in client-server environments, it is extremely difficult merely to gather that information into one place easily, let alone be able to work on it and make it concurrently available to others who need it.

"We needed a solution which allowed us to get at, use, quickly update, and share information no matter where it was," the doctor noted.

Wilford Hall used Digital’s LinkWorks Solution Framework as a foundation for this collaborative medical structure, designed to enable wider information sharing and other crucial benefits within the constraints of patient privacy and system security.

Working with a team from Digital, Wilford Hall built what is now called the Consult Tracking System (CTS).

Consult Requests

Among many other things, CTS enables Wilford Hall physicians to make electronic requests for consultations with specialty clinics -- military and nonmilitary. With the consult request entered into the workflow, the requesting physician can easily track the consulting physician’s examinations and reports, ultimately improving the patient’s treatment and medical progress.

CTS automates and expedites the tracking process, and gives physicians unencumbered update/detailing access to their patients’ records, helping medical practitioners focus on patients.

Called a physicians’ "electronic consult process," CTS enables primary care managers, clinical specialists, and other health care professionals to form virtual teams which can deliver higher quality patient care more efficiently than is otherwise possible. A second phase of this powerful, patient- and taxpayer-oriented solution will focus on management oversight and will extend the system to include additional military and private sector clinics.

But today, physicians are using consulting physicians’ evaluations to plan ongoing treatment regimens in a fraction of the time that was necessary when "paper" had to be chased. "Because we can quickly see and use pooled information, we can update patient treatments faster, which is better for everyone – especially patients," the doctor noted.

With their customized CTS, Wilford Hall’s managers -- from the smallest department to the biggest – have been able not only to improve the quality and speed of delivery of patient care, they have also been able to streamline and expedite all related business practices including billing. They have also effectively increased both their control over the data and the accountability of associates in the Military Health Services System, enhancing the efficiency of the entire team.

Because the CTS program’s extensive management and monitoring capabilities, including electronic signature authorization and event notification, streamline and improve the effectiveness with which Wilford Hall’s overall business processes can be managed, "That makes for better medical care," the doctor concludes. "But it also makes for a more efficient operation. So patients are happy, which is important. But taxpayers are very happy, too."

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In response to rapid-fire changes in computer technology and enormous market pressures, Digital’s sprawling Kanata manufacturing plant is replacing its paper-bound, manually controlled documentation and change process in favor of centralized, controlled electronic processes.

Kanata, Ontario, an Ottawa suburb, is the location of one of three worldwide high-volume Digital manufacturing plants producing Digital servers, modules, and PCs. It produces nearly $900-million (Cdn) in products annually.

Comments Robert Pariseau, Engineering Services Manager, "Our plant has been certified to ISO 9002 since 1991. Changing market requirements dictate that our products change rapidly. It was becoming increasingly difficult for us to manage our paper-based documentation and change process efficiently or effectively." He adds with a smile, "We reasoned in 1994 that if we continued with paper documentation, some out-of-rev documents would show up right around audit time. But there were clearly many other, more important drivers behind our decision to change.

"We needed faster turnaround on document review and approval," he continues, "since the average review time for change control requests then was 10-12 days. In some cases, the plant needed to respond to 5-10 changes per day on work instructions without holding up production. Changes needed to occur within minutes or hours, not days.

"We had no way to kill out-of-Rev paper documentation. The only solution to all our needs was to create on-line documentation. That way everyone could be certain they were working with the latest information."

To centralize information yet make it widely available for secure revisions required a flexible, powerful solution framework. The Kanata plant selected LinkWorks from Digital.

What Kanata Wanted

The Kanata plant’s objectives:

• Replace 25 hardcopy libraries with a single on-line library capable of delivering instant access to newly released documents
• Eventually provide hyperlinks to other documents and corporate standards published outside the plant
• Document and process changes quickly and release them on a controlled basis
• Reduce the annual >$2-million (Cdn) documentation management costs
• Reconcile the plant’s two documentation control processes; "owner-controlled" was fast but subject to breakdown in control, and "plant-controlled" was slower but more effective at controlling changes

"We had no requirement which dictated that we use a Digital product to solve these problems," Robert reveals, "but logically we found that LinkWorks was the right choice for us. It did what we needed done and had the flexibility to grow with us as our needs evolved."

In an extensive pilot project, the Kanata plant centralized revision control and access rights, sped up and automated the review cycle workflow, and enabled users to share, access, and maintain their own documents.

Consequently, the time to process documents fell from an average of 11 days to just 5 days. More important, Robert says, "As the system rolls-out into the remainder of the Kanata plant, document processing will drop to 2 days or less. We are already seeing instances where document changes are approved and released online within hours."

The Client-Server Framework

In the Kanata system, LinkWorks provides a client/server framework for an ISO 9000 compliant documentation management system. On that system are layered Microsoft Word authoring and viewing applications for creation and real-time distribution of controlled on-line documents. Annotations are stored in the document, which is shared by everyone involved in the review cycle.

The system automatically notifies the author of changes to document contents, which initiates a new review cycle.

The pilot project was limited to a specific production line and its support personnel --50 PCs supporting over 100 people. Other, far more extensive plant rollouts are now underway.

On the pilot production line, the new program:

• Can integrate legacy applications through VT-terminal and X-terminal emulators. Bar code readers were added to the PCs to allow data entry of quality data, plus module tracking. (LinkWorks does not store any of this data).
• Provides basic workflow capabilities coupled with electronic signoff capability to speed the review and approval process and provide an audit trail.
• Utilizes Microsoft Word as the authoring environment. Word is pre-encapsulated in the program; the business process was integrated using LinkWorks method modifications.
• Combines both prior documentation control processes, keeping the best attributes of each (speed/control)
• Centralizes revision control and access rights, automates and expedites review cycle workflow, and enables users to share, access and maintain their own documents
• Enables system access via PCs, guaranteeing that the latest document is always available to librarians and online users. (accommodates a hybrid on-line/hardcopy documentation process)

Plant Benefits

After processes had been fully automated, document turnaround time dropped from 11 days to 5 days or less.

The new system’s "share" capabilities allow a superior degree of control since sub-documents (like organization charts, workflows, CAD drawings, forms, etc.) referenced from several documents can easily be re-used.

LinkWorks Master Documents provide a "corporate style police" where authors need be concerned only with document content: built-in styles are applied automatically, further reducing authoring time.

Reductions in the need for author formatting, coupled with automation of many paper-based process tasks, are expected to cut yearly costs for managing controlled documents by 27%. Activity-Based Costing will be performed once the system is well implemented to measure actual results. "Once rollout occurs as planned, the system will pay for itself in its first year," Robert states.

The pilot project was implemented on a Digital AlphaServer 2100 running Windows NT, LinkWorks and Microsoft SQL Server. The networked PC clients communicate with the server over TCP/IP through UTP lines connected to a DEChub, which in turn connects to a Gigaswitch which ties the system together over an FDDI backbone.

"Flexibility is key," Robert Pariseau concludes. "We’re rolling it out plant-wide because it’s saving money for us, but we’re equally excited about its potential. There’s nothing that we’ve thrown at it where it has not saved us money."