=Paper=
{{Paper
|id=Vol-131/paper-2
|storemode=property
|title=Knowledge Management in Internal Medicine - Experience with Lotus Notes
|pdfUrl=https://ceur-ws.org/Vol-131/KMM05_No01_Bobrowski.pdf
|volume=Vol-131
}}
==Knowledge Management in Internal Medicine - Experience with Lotus Notes==
https://ceur-ws.org/Vol-131/KMM05_No01_Bobrowski.pdf
Knowledge Management in Internal Medicine–
Experience with Lotus Notes
Christoph Bobrowski, Georg Kreymann
Medizinische Klinik und Poliklinik I, Zentrum für Innere Medizin, Universitätsklinikum
Hamburg-Eppendorf,
D-20246 Hamburg
bobrowski@uke.uni-hamburg.de
Abstract. There is growing demand for the presentation and retrieval of
clinical guidelines which are relevant for the everyday usage of clinicians. An
intranet-based solution compares favorably to paperwork, but a standard web
based on plain HTML does not support very well features such as document
structuring and text retrieval. At the start of this project (year 2000), content
management systems were rudimentary and expensive. We have therefore
implemented an Intranet which is entirely based on Lotus Notes/Lotus Domino.
The essential advantages to this solution are the integration of full-text retrieval,
structured documents and document hierarchies into a departmental intranet.
1. Introduction
Within the department of Internal Medicine, there was demand for the presentation of
guidelines and of local procedural standards. An intranet solution based on a web
server alone was rejected because this solution lacked document structuring,
authoring, and workflow support. Content management systems (CMS), on the other
hand, were less developed then than they were now, and they were expensive.
Our essential requirements were: System development and integration costs should be
marginal, authorization and production of documents, should be supported by the
software. We decided to base the intranet entirely based on Lotus Notes/Domino.
Principles governing the design and the structure of websites containing guidelines
have been described before. e.g. by the American Medical Association [1] and the
National Guideline Clearinghouse project [2]. These principles have focused on
quality and efficiency. In the project described here, our very modest objective was to
get experience with groupware as a tool for document management in an intranet.
2. Material, Methods, and Clinical Setting
The Medizinische Klinik and Poliklinik I is a department of the University hospital's
Center for Internal Medicine of the Universitätsklinikum Hamburg-Eppendorf (UKE).
The department serves the specialties Pneumology, Endocrinology/Metabolism,
Gastroenterology/Hepatology, Infectiology, Intensive Care and Emergency
Admissions. There are 106 hospital beds and 13 ICU beds in the department. Server
and clients run under Windows NT4, newer clients under Windows2000. Hardware
was installed in the years 2000 and 2001. Lotus Notes/Domino Release 5 was used.
Network infrastructure consisted of the two disjoint networks of the hospital. The
"scientific net" is connected to the internet using UKE's web server, and the "medical
net" is used for patient care.
3. Results
Classes of relevant information were identified as follows:
1. Procedural orders issued by the the Department
2. Quality guidelines issued by the whole hospital
3. Medical information about laboratory procedures
4. Guidelines issued by the professional societies
5. Medical information from within the hospital but beyond the intranet
6. Medical information from the internet
The intranet based on Lotus Notes provides the user with documents from the above
classes 1 to 4. Guidelines from the professional societies were downloaded regularly
from the AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen
Fachgesellschaften). Information from classes 5 and 6 was not presented in the
intranet initially. Additionally, the intranet provides ancillary information: Local
"yellow pages" (who is in charge of particular medical functions in the department), a
rotation schedule, and the night shift schedule.
Lotus Notes provides a rich set of tools and functions. Of these, we have used the
following: Hierarchical organization within a document; hierarchical organization of
documents, hyperlinks; full-text searching, indexing by date, by author, and by
predefined "categories". All of these functions were implemented using Lotus'
predefined "document library". Indexing was realized by adding index fields to
documents, and the index structure was constructed manually. The associated Notes
designer form ("mask") was changed in order to present the indices. Construction
time for this was a few hours for experienced users.
A year after project start, access to laboratory results of the information system ixserv
was implemented. As ixserv presented its results as web pages, integration into Lotus
notes was easy. Two years after the start of our intranet, the hospital provided an
internet access using Citrix' metaframe technology. While this is an elegant means of
providing internet access from within a protected environment, integration with Lotus
was not feasible on the document level. In 2003, metafame based internet access was
opnened to the whole hospital.
Access to the medical information system UpToDate [3] was initially local to the
intranet. When metaframe technology was installed, the hospital as a whole
subscribed to UpToDate’s services. The end result was an internet access to
UpToDate instead of the local intranet access. The same migration path was
employed for the German coding software DIACOS: Once it became avaliable on a
dedicated server, the intranet provided access to that central service via metaframe
technology.
4. Discussion and directions for the future
The base hardware and the Lotus software have been reliable and stable. The intranet
was integrated into the physical network structure of the high-security medical
network of the hospital without any major problems. Management of service packs
and patches to Windows NT had been a time-consuming endeavour, and we highly
recommend to use patch deployment software in the future.
Once the hospital’s IT department was ready to provide services which were
essentially identical to ours, we moved to migrate our services to theirs. The success
story here is the integration of UpToDate (a web-based information service in internal
medicine and general practice) into the offerings of library IT at our hospital.
A major advantage of Lotus Notes is its "document" concept, incorporating full-text
searching and structured documents. This allows for a very easy construction of
polyhierarchical structures. A major disadvantage of Lotus Notes is that the look and
feel of Notes is proprietary. Thus it presents a third interface paradigm to the user,
given that Microsoft Office and the Web are ubiquitous. This has hampered
acceptance of this intranet, particularly for non-technophile users.
Lotus Notes has been tried as base software for clinical information solutions before.
Little is published in MEDLINE though, but there are interesting reports on Notes
based solutions in the web [5, 6, 7]. Most of these applications have centered on form
management and document management. In fact, Notes is very strong in these
applications, and it has the potential for inexpensive, successful solutions once the
Lotus Notes infrastructure is installed. Database access and access to archive tools
using Lotus Notes is, in our opinion, initially expensive because it requires the
management of a complex interface. Lotus Notes seems to be weak in the integration
of biosignal and picture information into documents [8]. Recently, efforts to foster
collaborative computing in a clinical setting have been supported by IBM’s new
Center for Healthcare Management [9].
Lotus Notes provides the user with a powerful set of tools for network-based
collaboration ("collaborative computing"). Moreover, the interface is proprietary. In
our experience, the estimated learning curve for Lotus Notes is intimidating for some
users. This can only be alleviated by a strong user support and by a firm commitment
to this "exotic" groupware solution. This is also true on the technical side:
Administering and customizing a Lotus Notes infrastructure requires access to
specialist knowledge. (In our case, we bought support from a Lotus Notes "third party
partner" for the initial phase.)
For a Lotus Notes based solution, there seem to be only two viable strategies:
Pervasive introduction of this groupware system, requiring also strong technical
knowledge of the system, or the usage of Lotus Notes "in a box" for limited projects.
In the area of content management systems, Notes now competes with a number of
commercially available or open source products for content management. In 2004, we
believe that a Notes interface to a CMS is not enough, both for the readers and the
authors.
We are convinced that departmental intranets need content management systems
(CMS) in the short term because only CMSs provide easy management of authoring,
versioning, access control, and security defined by "users" and "roles". A CMS might
be termed middleware, representing an additional layer on top of base software such
as Lotus Notes. Giving a web interface to users is an additional strong asset.
5. References
1. Winker MA, Flanagin A, Chi-Lum B, White J, Andrews K, Kennett RL,
DeAngelis CD, Musacchio RA. Guidelines for medical and health information
sites on the internet: principles governing AMA web sites. JAMA 2000; 283 (12):
1600-6.
2. Bernstam E, Ash N, Peleg M, Boxwala A, Mork P, Greenes RA, Shortliffe EH,
Tu S. Guideline classification to assist modeling, authoring, implementation and
retrieval. Proc AMIA Symp.2000; (20 Suppl): 66-70
3. See the homepage of UpToDate, Inc.: http://www.uptodate.com (Accessed
Nov 21, 2004)
4. See the homepage of the makers of DIACOS, ID GmbH, at
http://www.id-berlin.de (Accessed Nov 21, 2004)
5. Report on a Lotus Notes solution at LaGrange Oncology, LaGrange, Illinois:
http://www.eletra.com/rainmakers/e_article000057538.cfm (Accessed Nov 21,
2004)
6. Report on a Lotus Notes solution at Cincinnatti Childrens’ Health Medical Center:
http://radio.weblogs.com/0105504/categories/Random (Accessed Nov 21, 2004)
7. Transcription and forms management system at Carson City Hospital, Michigan:
http://itpapers.zdnet.com/abstract.aspx?scid=&kw=domino&dtid=3&docid=81566
(Accessed Nov 21, 2004)
8. We thank a reviewer for pointing this out.
9. Compilation of healthcare applications compiled by IBM’S Center for Healthcare
Management: http://www-1.ibm.com/services/us/bcs/html/chm_overview.html
(Accessed Nov 21, 2004).