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Curbside Consult with Dr. Jayne 1/30/12

January 30, 2012 Dr. Jayne 4 Comments

Don’t Take Me Out of Context

Depending on the size of the communities they live in, CMIOs can sometimes feel isolated. Some may work in cities with multiple hospitals and health systems and have easy access to peers (and getting together over drinks is certainly fun!) but many work in towns with only one hospital. For the latter, finding and collaborating with peers can be a challenge.

I belong to a virtual community of CMIOs that contains a mix of big-city and small-town CMIOs. There are a couple of former CMIOs and a couple of young pups just starting out in informatics thrown into the mix as well. It’s been a great resource for idea sharing over the last several years and has helped me preserve my sanity on numerous occasions.

We recently got into a discussion about single sign-on options. Even those hospitals with single-database systems often have legacy systems with which clinicians need to interact. They also need to access a variety of homegrown and interfaced applications in order to care for patients and manage clinical data. Many hospitals have tackled this with single sign-on, proximity badges, or other strategies to reduce the need for clinicians to manage multiple passwords.

I’ve used several of these solutions and they are undoubtedly cool. However, they lack the ability for clinicians to rapidly access a single patient across multiple systems. Providers end up searching for the patient in multiple applications while they try to mentally create a unified view of the patient. This is less than ideal. One of the young pups in the group mentioned that he was looking at context-sharing solutions in an effort to remediate this problem. Luckily we have a few CCOW aficionados in our group. For best-of-breed shops, this can be essential to efficient access by clinicians.

For those of you who don’t know where I’m going with this, let me introduce you to CCOW. CCOW stands for Clinical Context Object Workgroup, which is an HL7 standard that allows clinical applications to share information. Through this standard, applications can participate in both user context sharing and patient context sharing.

From a practical standpoint, this means that when the clinician accesses a patient chart, all other applications that the provider is accessing synchronize to that patient. When user context is also included, it may also facilitate reduced sign-on into applications which are subsequently accessed. CCOW can go deeper than just user and patient context – encounter context can also be included.


CCOW (thanks to Health Level Seven, Inc. for the graphic) is often misunderstood by clinical and IT people alike. Although many vendors create their applications to be CCOW compliant, this does not mean that just installing two of them will “automagically” link them together. Context management is required. When the systems lack a shared master patient index or a common patient identifier, an intermediary mapping agent may also be necessary. Dedicated context management software may also need to be installed locally or on servers to help synchronize client-server and Web-based applications.

CCOW also doesn’t magically move data from one application to another. It simply allows users to access information on a single patient across disparate applications with a minimum of fuss and bother. Depending on the setup of the environment, CCOW may not work the same for users accessing from home or from non-network devices.

The use of CCOW also creates additional testing requirements during application upgrades in order to ensure that functionality remains unchanged. I know of at least one major vendor whose CCOW functionality has been negatively impacted by an upgrade, causing much consternation to the numerous hospitals live on its product.

There are multiple context managers out there, including Microsoft’s Vergence product (formerly of Sentillion) and Carefx Fusionfx. The fate of the Vergence solution is one reason that the recent Microsoft / GE Healthcare joint venture (first reported by Mr. HIStalk back in December) makes a lot of people nervous. Customers were already twitchy after Microsoft acquired Vergence from Sentillion in 2009, with reports of a decline in customer service and support.

Quite a few significant players in the hospital industry are customers, so hopefully that will be incentive enough for the as-yet-unnamed entity to resist making a mess of it. (Any idea on that name? I’ve been keeping my eye out, but haven’t seen anything, and there’s nothing on the Microsoft Health Web page yet, either.)

Most of the big vendors are CCOW compliant, but there are still some who don’t understand the value proposition to clients. Far from a gimmick or a “nice to have” feature, for organizations such as Mayo Clinic, Johns Hopkins, and many more, it’s essential. Once again, I was grateful to my CMIO coffee klatsch for a good discussion and plenty of humorous anecdotes. I’m looking forward to catching up with y’all at HIMSS12 in just a few short weeks!

Have a question about virtual networking, best-of-breed systems, or what the new Microsoft/GE entity should be called? E-mail me.


E-mail Dr. Jayne.

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Currently there are "4 comments" on this Article:

  1. The thing that killed the CCOW initiative is that, when it finally gained traction within HL7, the choices for enabling middleware were extremely limited. Initially, there was ONLY Sentillion, and to make matters worse, Rob Seliger was the head of the HL7 CCOW group, as I recall. Now Rob’s a great guy, I’m sure. But when you have the head of the “neutral” standards group be the same guy as the CEO/Founder of the ONLY company selling software to execute the standard, that’s uncomfortable. We and many other organizations back 8-10 years ago mandated CCOW-compliant best-of-breed and were then burned with a bill for another few hundred thousand buying Sentillion to actually make it work–with no competitors on the horizon. Carefx and others came along, but by then we–and others–were pretty peeved and the whole idea lost a huge amount of momentum.
    Just another sidebar to this sorry and sordid industry that I love so much.

  2. I was surprised that Meaningful Use has not covered the patient safety issue of having data for multiple patients on the screen at one time and the caregiver mistakenly thinking they are looking at the same patient.

  3. TEST TEST TEST and TEST again for CCOW!!!

    Our large community hospital got one of the single sign-on solutions and we piloted it in Medical Records where coders and others have to access at least 7 applications to see a full chart. The project failed.

    The fluidity of the workflow (changing patients in one application or the other) exceeded the ability of the SSO product to keep up. Once it became apparent that if we rolled this out to our entire organization that clinicians would risk being out of context while placing orders — it was all over.

    It is a great idea and I’m hopeful that the vendors will resolve the issues. I think it takes more than the SSO vendor to make sure that context is preserved. You should be able to change patients in any of the linked applications and ALL of the CCOW-compliant applications should change to that patient (and quickly).

    It’s a challenge!

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