From the novelty to the norm

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With a heritage of more than a hundred years existence, the Dublin Dental School and Hospital (DDSH) has been treating patients and imparting the skills of the profession to aspirant dentists since the days when information technology amounted to chalk and blackboards.

Today, 106 years after the founding of the original Dental School in 1898, DDSH has at any time during term some 200 undergraduate students, between 20 and 50 post graduates and about 200 staff. It has a three-fold responsibility: teaching students; carrying out dental research and providing patient services.

Over the past decade or so, computers and electronic communications have made their way into every one of the School and Hospital’s departments. ‘When I started here in 2000 we had four servers,’ said Luke Feeney, Information Systems Manager, ‘now we have 21 covering all manner of applications.’ These include back-office administration such as human resources and stores management, through patient management and on to supporting and managing the teaching and learning processes of the students.

That is as it should be, according to Feeney. ‘I’ve always been of the mind that IT shouldn’t be just a support function; that it should integrate into the very culture of the school and hospital,’ he said. ‘That’s what we’ve been doing since day one. Our eventual aim is to integrate IT into our day-to-day operations so that we have a paperless dental school. That’s our Nirvana.’

While striving for this state of bliss, however, it is important not to neglect the overall purpose of the organisation. ‘We’re always very careful that we don’t go running down the avenue of using IT to automate and improve efficiencies and processes,’ said Feeney, ‘and losing sight of the missions and goals of the School and Hospital which are to provide excellence in student education, research and
patient care.’

World first
Until the early 1990s, all patient administration, including appointments and clinical records, was paper based. By contrast, since April this year, all new patients’ records, including radiography, are stored electronically. Feeney believes that DDSH was the first teaching dental hospital in the world to have such a complete electronic record of its patients.

In 1994, development began on a DOS-based patient-management system called PRS (Patient Registration System) which went live in 1996. This was purely an administrative system with no clear clinical component.

At that stage the DDSH had decided strategically to move to a Windows-based system. Development on that began in 1998 and it was installed in August 2000. This system is called Salud and is the key mission-critical application that the DDSH runs, according to Feeney.

Salud is an enterprise-wide clinical information system that was originally developed as a custom project for DDSH by an Irish specialist software house called Two Ten Health but it has since been installed in several other institutions
around the world. According to Feeney, Two Ten Health is one of three main players world wide specialising in clinical information systems aimed at teaching hospitals, as opposed to dentists in private practice.

Salud manages all aspects of patient interaction with the DDSH from clinical management, ie the patient’s electronic dental record, to appointments, finance and ancillary services such as sterilisation management . It also handles all the academic management of students and has a major reporting function.

The system is hosted onsite and runs on an Oracle back-end database. The main Oracle server is linked to a secondary server to which the database is backed up every 30 minutes. If the main server fails, there is a plan already in place to ensure that there would be only 20 minutes downtime before the backup server could be brought up. ‘In addition to that obviously we have nightly tape backups which are stored in a fire-proof safe on site, with a copy off-site as well,’ said Feeney.

Salud is at the core of everything the DSSH does and several additional capabilities have been, and are being, added to it. Examples include a ‘best of breed’ digital radiography product. Nearly all radiography in the hospital is captured and transmitted digitally. Wet-film processing is now only used for training purposes and for a special type of radiograph that can not yet be captured digitally.

Another recent addition to the Salud system is an application that allows notice of patient appointments to be sent via SMS to their mobile phones. That is due to go live this September.

Both of these additions to Salud are independent ‘best-of-breed’ applications that have been tightly integrated with Salud. ‘It’s not just a case of Salud calling the digital radiography system,’ said Feeney. ‘The permissions for access are all done within Salud and are then passed out of the Oracle database to the radiography
system which runs on a separate database called Solid Server.’

The integration with the SMS application was slightly different. An automated query of the Salud database generates a list of patients and mobile numbers for appointments within certain date filters which the DDSH staff apply. That list is then sent as a CSV file to the SMS system so that a single message can be sent to all patients in the group.

Recently the DDSH has installed an open-source reporting product called Agata, which provides additional automated reporting capabilities over and above those available from Salud. This allows reports to be scheduled automatically and sent to students.

‘The latest integration we are looking at, and the next step on the way to a paperless office, is an electronic signature system,’ said Feeney. This is based on a product called E-pad, developed by Wicklow company Identity & Security Solutions. ‘This will remove the need to print out treatment plans for patient consent and is the next step on the way to a paper-less office. We are working
with Two-Ten Health to integrate that into Salud.’

‘Outside of the clinical application system, all other processes such as our salary systems and stores management systems are electronic,’ said Feeney. ‘They’re not totally integrated at the moment, but we’re working towards integrating our payroll system with our HR system and so on.

Furthermore, e-mail has become the de facto method of communication and the DDSH is also redeveloping its intranet using an Open Source product called Mambo. ‘That’s to improve the idea of the electronic culture within the organisation,’ said Feeney.

Feeney and his team are kept busy. IT accounts for about 6 per cent of the DDSH’s overall budget but the team is relatively small. ‘There are eight people in the IT department including myself,’ he said. ‘We are not just IT, we call ourselves IS. We provide the traditional IT support function, but also support all the audio-visual systems used in the lecture theatres. We support all the applications, including Microsoft Office and manage and support our Meridian PABX system using Phone Master.’

As well as that, his team is responsible for all IT training in the School and Hospital. ‘In August 2000 we became an ECDL training and testing centre,’ he said. ‘It’s now part of the student curriculum and also a requirement for all staff to pass ECDL. So we provide all of that training and testing. On average we put about 60 people a year through ECDL. We’re kept busy.’

Is it part of his role to decide on the technological future of the organisation? ‘Absolutely. As information systems manager it’s my brief to have an appropriate strategy in place. We have a hospital executive, of which I’m a member, and a hospital board. We have to go through those channels to get strategy approved. In 2000 we got approval to go to electronic records.’

Is the paperless office towards which he is striving a realistic goal or a mythical Nirvana? ‘The immediate hurdle is to become clinically totally paperless,’ he said, ‘We have challenges with patient consent, and we’re looking at ePad to handle that. We need the ability to scan in extraneous pieces of paper such as letters of
referral from outside the school so that we can attach them to the digital record. Two Ten Health has developed a document-management system to allow us to do that. We already have a medical scanner that allows us to scan in radiographs that come from outside the school and attach them to a patient’s record.’

Another project he is looking at is a self check-in system for patients whereby a patient could log in at a kiosk with a touch screen or a barcode and their details would then be carried to alert the student or clinician who is expecting them. That facility already exists in Salud, but is currently invoked by an admissions
clerk.

The next stage will be to look at financial systems and allow invoicing and purchasing to be performed digitally. ‘It’s all about moving IT from the novelty to the norm,’ said Feeney. ‘When mobile phones first came out, people thought they were a great novelty. Could we live without them now?’

Data delivered to the dental chair
Students working on real patients have access to key applications from their chairs in the dental clinic, thanks to a thin-client network of PCs based on Citrix nFuse.

Working with a patient, the student can log on to the network and have applications such as Acrobat Reader, Microsoft Office, Outlook, Internet Explorer and the key Salud clinical-information system delivered to their screens. Students can view the patient’s electronic record, including radiography, from the Salud application.

As the delivery mechanism is Citrix nFuse, they are only receiving screen refreshes from a server farm, which makes administration of the system very easy from the IS department’s point of view. However, starting this term, the back end has been changed, as part of a pilot to investigate Linux on the desktop, for one of the clinics which comprises 40 workstations, from a Windows server to a Linux server and a Mozilla browser.

According to Feeney, the system now ‘boots up in Linux, opens up Mozilla’s Firebird browser and connects to nFuse. Even though it looks and feels exactly the same as Windows 2000 the background is now Mozilla and Linux.’ This provides a greater degree of security to the back-end server, offering much greater immunity to hacking and/or a virus attack.

The idea was suggested to Feeney after his first encounter with open source software, which was an e-learning tool called Moodle which was deployed with the help of Enovation Solutions, an open-source services company.

‘When I was attracted by Open Source, Enovation Solutions suggested a Linux based kiosk for the dental clinics,’ he said. ‘We’ve installed it into one of the clinics and the big tester will be when the students come back in September. We’re going to see their reaction and whether there will be any issues. We don’t think they’ll see a difference.’

Feeney says the DDSH will try it out in one clinic for a month and if all goes well, will deploy it across all the clinics in the school and hospital.

The DDSH uses a number of open source applications including the Moodle e-learning system, the Mambo content-management system for its intranet and the Agata automated-reporting tool. It also hosts two international Web sites, for the Association of Dental Educators of Europe and a thematic dental site called Dent Ed, which are based on a Linux server.

However, although pleased with the performance to date, support issues are causing him to tread cautiously before moving further down the open source road. ‘We have a huge amount of in-house expertise on Microsoft applications but little or none on Linux and open source,’ he said. ‘I need to be sure that we have developed our own inhouse expertise to support open source, so that’s one
of the blocks at the moment. So we are leveraging the benefits of open source, but for the most part, we are still siting the applications on non open-source servers.’

11/10/04

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