Father-Son Doctor Team Aims To Revamp Hospital Business Intelligence

A father-son team of physicians has taken aim at the medical field -- notoriously behind the curve when it comes to using business intelligence to gather and analyze data, especially hospital records -- with a software product that combines elements of both business process management (BPM) and BI analytics. Called Micro-Cares, the product tracks the treatment of patients in a hospital setting, and its creators say it could represent a revolution in how doctors think not only about patient care, but the training of physicians.

Dr. James Strain, a psychiatrist at Mount Sinai Hospital in New York, and his son Jay, a surgeon in the San Francisco Bay area, take an idealistic view toward their Micro-Cares project. "We're not in this for the money," the younger Dr. Strain says. "Or goal is simply to make something that works."

For decades, hospitals have struggled with the computerization of patient records. At most institutions, dozens of home-grown legacy systems are scattered throughout the organization, with little interaction between them. Funding is often a problem -- hospitals generally have little money left over to spend on IT upgrades -- and so is compliance. Privacy issues make it difficult for doctors to share patient data, a status quo that ultimately impedes research, many clinicians says. Doctors in one part of the country or the world might be getting high-quality results with one form of treatment on a certain disease, but if they can't communicate this or even locate the trend with any efficiency, it does no wider good. For the Strains, it is precisely this sharing of information -- while at the same time maintaining patient privacy -- that has motivated their move into the software field.

There are several pieces to the Micro-Cares product, the primary being CISCL (which stands for "Clinical Information System, Consultation - Liaison psychiatry, a form of psychiatry practiced in acute-care general hospitals for the treatment of mentally ill patients.) CISCL is an electronic medical-records tracker and database, and its roots go back to 1979, at the psychiatry department of Mount Sinai, where James Strain has worked for 26 years, including as director of the hospital's division of behavioral medicine and consultation psychiatry. Strain and a few colleagues undertook a massive project to come up with a dataset, a group of standard variables -- what the BI world would call "key metrics" -- in an effort to create a patient and treatment information system that would allow for the robust mining of all the information collected.

The basis for the system would be a set of uniform codes, each corresponding to a piece of information: patient complaint, patient demographic, status of consultation, lab tests, psychiatric diagnosis, eventual treatment and prognosis. The list was long and the process arduous -- some 300 variables were isolated after fifteen years of work. A computer database was created, originally on an IBM 370. As a boy, Jay Strain even helped his father on the project, working as a key-puncher. Since those early years, the program has gone through many iterations. The Strains began marketing the product as Micro-Cares four years ago, and the latest version uses handheld Palm Pilots as the core piece of hardware. Doctors make their rounds with the devices; the visual interface is a menu of tools that allow physicians to make inputs during each patient consultation. Surveys and questionnaires collect demographic information and other basics, and can be tailored and generated on the fly. Episode data, such as patient complaints and notes on the case by the attending physician, can be entered through a variety of pre-determined codes. Diagnostics and medications are, of course, tracked as well. Another Micro-Cares program called Literature Search, a homegrown archive of important medical papers, with commentaries written by experts commissioned by the Strains, can be accessed from the handheld devices to help doctors treat patients. When rounds are complete, doctors perform a hotsync between their handheld and a desktop, which is capable of handling the data load. The software can produce reports, mostly in Excel spreadsheets or in Word documents, based on all the gathered patient and consultation data, and can be queried based on almost any parameter -- the typical "drill down" capability familiar to BI users.

Doctors can customize the data-gathering process based on their clinical interests. "Very quickly people can come up with the paradigms they want in order to track data," Jay Strain says. "The hospital across the street might want to track different things, but they can still share their results. Our system is designed around the concept of bi-directional data transfer. It's not just dumping data off the Palm. It's not just a carrier of data. It's bi-directional -- all physicians, in other words, have all access to all patients and their data."

Indeed, this was motivating idea behind the system in the first place. Although relatively speaking Micro-Care's use has been limited, already it has yielded its fair share of clinical research, including over fifty papers from the Mount Sinai psychiatric unit alone, many written by James Strain.

Elsewhere, the sharing of data has led to insights with quite practical results. After the psych unit at a hospital in Taiwan recently implemented Micro-Cares, Taiwanese doctors discovered that a certain mental condition had an 85 percent success rate when treated with meds. In the US, where the success rate was much lower, the standard therapy had been counseling. Now, psychiatrists in this country might take a longer look at the use of drugs in treating the condition. Only by sharing data, the Strains say, could such an insight have been gleaned. Jay Strain's early experience working on his father's database seems to have influenced his later career. Not only did he receive a degree in medicine from Duke, but a master's in computer science, specializing in medical informatics, from Stanford. Micro-Cares' chief programmer, he now divides almost half his time between surgery and coding. Micro-Cares uses a relational database based on SQL, "the most straight-forward and cost-effective way to store data," Strain says. This has also allowed him a degree of flexibility not seen in most medical-record systems, which are complex and heavy-duty. With CISCL, a single doctor can use Micro-Cares to track his own case load, or whole units can, with minimal adjustments. "No other system can be dropped so easily into a hospital," Jay says, citing the Taiwanese example.

Primarily, CISCL is being used by psychiatric units -- about 60 of them, both large and small, at hospitals and clinics in the U.S., Spain, Portugal, Brazil, Mexico and Taiwan (languages are easily flipped in the CISCL interface). But the Strains have plans to broaden Micro-Cares' audience to include other disciplines, which would entail modifying the datasets. Jay Strain says he's currently working on systems designed for surgery, internal medicine, geriatrics and pediatrics. At Slone-Kettering in New York, a pediatric oncology unit is currently experimenting with CISCL.

Profit doesn't appear to be the object: often, the Strains will give the software away. At other times, they'll arrange funding from outside sources to help pay for the cost of equipment and setting the system up. Eli Lilly, for instance, funds the program's use at a hospital in Portugal.

There has been some resistance to its implementation, however. At Memorial Hospital in New York, the psych unit discontinued its use of Micro-Cares because of a mandate from on high to use only the hospital's legacy computer systems for storing records. And at a hospital in Australia, use of Micro-Cares has also been discontinued, after the head of psychiatry, a CISCL supporter, retired. "You have to have someone in there who's interested in monitoring data, seeing its quality, and working with it," James Strain says, explaining the situation in Australia. "But his successor wasn't interested in doing all that work."

Perhaps because of this resistance, the Strains are working hard to market another piece of the Micro-Cares line, called MedTrack, which is almost the inverse of CISCL. Instead of tracking patients, it gathers information on the performance and experience of medical students. The goal is to make sure that students receive adequate training. As they make their rounds, students use handheld devices to record which patients they've seen and what they've done while administering to them. The Strains' idealism shines through here as well. Jay strain says, "Did they observe, or did they perform, or did they teach a procedure as a medical student? That information has never been captured before. Did they deliver a baby or experience a drug-drug interaction? Or did they get through medical school without delivering baby, without seeing drug-drug interaction? I think there's a tremendous gap between where we could be with our teaching and where we are now."