The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment

doi:10.1016/S1386-5056(99)00007-6

International Journal of Medical Informatics

Volume 54, Issue 3, June 1999, Pages 197-208

https://doi.org/10.1016/S1386-5056(99)00007-6 Get rights and content

Abstract

The Brigham integrated computing system (BICS) provides nearly all clinical, administrative, and financial computing services to Brigham and Women’s Hospital, an academic tertiary-care hospital in Boston. The BICS clinical information system includes a very wide range of data and applications, including results review, longitudinal medical records, provider order entry, critical pathway management, operating-room dynamic scheduling, critical-event detection and altering, dynamic coverage lists, automated inpatient sumaries, and an online reference library. BICS design emphasizes direct physician interaction and extensive clinical decision support. Impact studies have demonstrated significant value of the system in preventing adverse events and in saving costs, particularly for medications.

Introduction

Brigham and Women’s Hospital (BWH) is a 720-bed academic medical center located in Boston. BWH admits 40,000 inpatients and sees 700,000 outpatients annually in hospital practices and community satellites. Clinical practice covers the entire spectrum from primary care to tertiary and quaternary care. A wide variety of teaching and research programs are carried out; BWH is the second largest independent recipient of US government research funds. Created from the merger of three hospitals in 1980, Brigham and Women’s in 1994 became a cornerstone of another merger when it joined with Massachusetts General Hospital to form Partners HealthCare System, an integrated delivery network that currently includes ten hospitals and over 250 practice sites.

The story of information systems at BWH is primarily the story of the Brigham Integrated Computing System (BICS), a fully-integrated system that handles the large majority of clinical, financial, and administrative computing needs of the hospital. Clinical computing at BWH began as a port of the Beth Israel Hospital (Center for Clinical Computing) minicomputer-based MIIS system [1] in 1984; some of the fundamental software still owes its parentage to that system. Independent development has proceeded at BWH since 1988. Initial BICS development focused on two primary goals. The first goal was to establish a new client-server technical platform that would support the hospital’s continuing expansion, and provide the processing power and scaleability needed for future developments. The second goal was to build new clinical information systems that would change the computer’s role in the health care process. Moving up from its traditional role as a reporter of requested facts, the computer would become an active partner in promoting optimal quality of care, reducing adverse events, and reducing cost.

The successful realization of these goals is due to a combination of several factors: strong organizational support for information systems, favorable technical design calls, a software design strategy focused on the caregiver’s information needs, intensive groundwork from information systems management to prepare the institution for major cultural change, quick responsiveness to user feedback, and an emphasis on evaluation of the computer’s effect on care and cost.

Section snippets

Objectives

Clinical systems development at BWH is based on the following principles:

1.
Broad content. The BICS database should contain as much relevant clinical information as possible. Special emphasis is given to data which can be encoded and used for guidance of care and decision support.
2.
Workflow support. Programs and screens should be based on clinical scenarios (for example, an initial outpatient visit) and should display together all information useful for that scenario. Data that is going to be needed

Technology

In 1988, as noted above, BWH grew out of the original minicomputer-based platform. The technology planning team settled on client-server technology, relatively new at the time, for its much greater processing power per dollar, and for the benefits of using industry-standard commodity hardware [21]. The next problem was how to convert to the new technology, known as TNP (The New Platform) without significant disruption to existing usage. By creating an interim link from the old hardware to the

Management factors

Although BICS has a number of innovative design and usability features, these are not sufficient by themselves to gain user acceptance. Applications such as order entry and the ambulatory record still cause a significant change in the way providers work. Without sufficient management support, pre-implementation consensus building, and post-implementation support, it is likely that no system, no matter how well designed, would survive the change process [23]. We note several specific factors

Impact of clinical information systems

As mentioned above, the hospital has a strong base of health services research. Care processes are constantly analyzed for effectiveness and for sources of adverse events. One analysis has shown that 23% of all inpatient adverse events on a medical service could be prevented by improved information systems that are within our reach [25]. The clinical IS research and development group views such research as a ‘to-do’ list. By this time, a substantial number of software tools are available to

Future work

A single IS department now manages information systems for all of Partners HealthCare System. BICS still functions as the major information system at BWH; however, the age and size limitations of the platform (both TNP and MS-DOS) limit our ability to simply drop these applications into other sites at Partners. We are moving to a Windows NT-based Mumps system which will improve this growth potential. Combining forces with information systems teams from Massachusetts General Hospital and other

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The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment

Abstract

Introduction

Section snippets

Objectives

Technology

Management factors

Impact of clinical information systems

Future work

Ann. Emerg. Med.

Jt. Comm. J. Qual. Improv.

Role of computing in patient care in two hospitals

M.D. Comput.

Designing systems for acceptance by physicians

Design considerations in the BWH ambulatory record: considerations for maximum acceptance by clinicians

Symp. Comput. Appl. Med. Care

Converting narrative text outpatient problems to coded problems

Proc. Am. Med Informatics Assoc. Spring Congress

Design of an easy-to-use physician order entry system with support for nursing and ancillary departments

Proc. Symp. Comput. Appl. Med. Care

Response to a trial of physician-based inpatient order entry

Proc. Symp. Comput. Appl. Med. Care

Transitioning clinical decision support from the hospital to the community network

Healthc. Inform. Manage.

Automated evidence-based critiquing of orders for abdominal radiographs: impact on utilization and appropriateness

J. Am. Med. Informatics Assoc.

Does the computerized display of charges affect inpatient ancillary test utilization?

Arch. Intern. Med.

Enhancement of clinician workflow using computer order entry

J. Am. Med. Informatics Assoc.

Implementation of physician order entry; user satisfaction and self-reported user patterns

J. Am. Med. Informatics Assoc.

Detecting alerts, notifying the physician, and offering action items: a comprehensive alerting system

J. Am. Med. Informatics Assoc.

Representing hospital events as complex conditionals

J. Am. Med. Informatics Assoc.