Telephones
The current CMH phone system is a digital Rohm system (see http://www.rohm.com/). The system management and maintenance is the responsibility of the CMH IM Department; they outsource these functions to a third party vendor. IM has one oversight administrator managing the vendor and its two employees who maintain the phone system. This very thin staffing results in long delays to implement projects and has led to periods as long as a week with no staff on hand who can handle phone problems.
The standard phone system either results in a call being answered, dropped or transferred into voice mail. Dropped calls result from the inability of the standard system to simultaneously permit conversations and diversion of callers to voice mail; callers also are not provided information about the situation. The most advanced systems offered to divisions are automatic call distribution (ACD) phones. ACD groups manage calls routed to them. Calls are distributed to the group using business rules that are computerized and based on availability of open phones and time in a phone cue. ACD group members log in and out and set their workflow status as available or not. ACD reports are standardized and summarize the activities of each ACD unit and staff member of the group. The data is not accessible for secondary processing and is not linked to the medical record in any manner. ACD technology manages the phones per se; there is no consumer service management component to the ACD technology apart from recorded messages informing the patients that they are in a cue.
As currently configured at CMH, only one ACD line can be present on a phone and triaging is rigid. Because so many functions are carried out in a busy clinical office, this single ACD group limitation essentially creates several isolated workstations, each for a single function. Also, we do not have technology-supported cordless or wireless phone capability in rather large office spaces and personnel are required to stay close to their phones, restricting their ability to retrieve charts or perform other duties simultaneously. Cell phones have been banned from the hospital.
CMH currently has a small pilot project using advanced IP phones. The PTTF found, in discussions with IM, that there was significant reluctant to move towards these systems. They rightly point out that the existing systems do work. Newer technologies, such as wireless and IP phones are not, in their opinion, as robust.
Fax Machines
CMH fax machines are typically multifunctional units that have printing and fax capabilities. Incoming faxes are printed at the local machine site. Outgoing faxes may come directly from users personal computer or by manual faxing from the machine itself. The printing occurs through the CMH Network hub. The advantage is that printing can be directed to any site in the entire CMH Network, including satellites.
Paging
CMH physicians have beepers. They receive a beep or buzz to prompt them to look at a call back number. They then call the number to retrieve the message or communicate with the initiator. A few persons have one-way text pagers and can receive additional text information. Physicians elsewhere in the Northwestern system have text pagers. As a consequence, some CMH physicians will carry two pagers and take advantage of the superior nature of the text pagers. Paging a CMH physician from outside the hospital is difficult.
Networks
The CMH network structure has evolved substantially in the past few years. The current structure, greatly simplified, is illustrated below (see figures 1 and 2). (Not illustrated for the sake of simplicity are the secure links to satellite clinics/hospitals.) Internally, the hospital is now wired with high-speed cable, facilitating the rapid transmittal of data including the demands of radiology's PACS. The hospital maintains a secure server farm on-site. These servers support all the current computing functionalities at CMH. Data back-up, server maintenance, and ongoing support occur on-site. These tasks are managed by hospital IT staff with the aid of contracted support services.
Figure 1. Basic CMH Infrastructure
Figure 2
Currently, no full scale wireless network exists. A test environment has been set up in the emergency department. Plans call for hospital-wide wireless to support the upcoming pharmacy bar coding system.
The users of the network fall into three broad categories:
Clinical users has seen a organized upgrade of the computing devices they use. Almost all PCs are now reasonably modern (Pentium III or greater) and are running Windows 2000, a far more secure and stable operating system compared to Windows 95 (the previous operating system). A major development has been the deployment of the Citrix-Single-Sign-On approach to accessing clinical systems. The Portal provides a controlled, secure environment for access to protected data. When a user logins into the portal, a server in the server farm creates a "virtual PC". This separate virtual PC is unaffected and isolated by the conditions on the users desktop. This model does, however, require a substantial amount of computing resources. As the Portal was rolled out, there were some delays for users logging in. This problem has improved as IT has added redundancy to the system. This model also allows IT to deploy "thin clients" - PC like device that have no hard drive and serve only to connect to the Portal. These device restrict the end users ability to modify their systems and reduce support needs.
Administrative users and academic users have similar systems - most have newer PCs running Windows 2000 provided and administered by CMH IT. Some users have hospital configured laptop PCs that also access the network. These PCs are not controlled as tightly as clinical desktops. While users are given access to the Portal, they have rights to add software and change configurations of their PCs to some extent. IT enforces some control using Policies, a Windows control that allows network administrators to block users from carrying out certain functions. For example, a user cannot change the appearance of his/her desktop. While not foolproof, this model provides for a balance of control.
The CMH network is protected by a firewall. This is a software and hardware system that prevents unauthorized access to a private network. It allows IT to monitor in and outgoing traffic, prevent access to certain types of resources (file-sharing networks, streaming video), and detect and prevent the spread of email virus. CMH has hired a network security specialist who continues to improve and refine the security of the network.
CMIER users exists in a special category. While their network is administered by CMH IT, it exists separately from the rest of CMH. This was done to provide greater access to outside resources to CMIER staff while maintain control over protected clinical data on the hospital network. CMIER users must connect to the hospital using a Virtual Private Network (VPN). A VPN allows for a secure, authenticated connection between a network and a user outside the network.
Home users will benefit from the development of the VPN (see also Security). Currently, a beta test of the VPN for home use is ongoing. Plans are to provide all physicians home access to the Portal. This will require users to have a password and a special key chain device that generates a random, changing number. This provides for a secure, authenticated connection. The user most also have a high-speed internet connection at home.
The purpose of the central data repository is to provide a single, common collection of all clinically related data. This is covered in detail in the Children's Computing Resource Center document.