Patient management solution for Oral Anticoagulant Treatment (OAT). TAONet ensures better quality care for patients and support for the physicians and nursing units involved in the management and control of OAT.

Roche has its headquarters in Basel (Switzerland). It is a leading healthcare multinational, specializing in pharmaceuticals and diagnostic products. With some 70,000 employees in 150 countries and a major R&D program, Roche is one of the world’s principal suppliers of diagnostic products, the largest manufacturer of cancer and transplant drugs and a leader in the field of virology. Its Pharmaceuticals Division made sales of 27,300 million Swiss Francs in 2005, and the Diagnostics Division 8,200 million.

Roche Spain has some 1,600 employees and total revenues of around € 838 million.

• Roche Farma is actively involved in the development and production of new drugs that have made a significant contribution to the progress of therapy and the emergence of treatments for formerly incurable diseases. Its cutting-edge production facility in Leganés (Madrid) is one of Europe’s most modern plants. It manufactures and exports pharmaceuticals to over 40 countries worldwide.
• Roche Diagnostics is based in Barcelona. Its activity centers on the creation of innovative products for fast, accurate diagnosis of a range of diseases, and for their subsequent control.

The challenge

Trends in the design of applications in the health sector have changed radically over the last 4 years, and it has become vital to offer open, flexible solutions that can adapt to change, are accessible and can be easily integrated with other systems. Meanwhile, information systems have become ever more important in the choice of providers by health departments.

In this new scenario, Roche Diagnostics opted to develop a patient management solution for the Oral Anticoagulant Treatment (OAT) based on a completely new and innovative approach in the sector.

Oral anticoagulant treatment (OAT) is used for the prevention of Embolic Thrombosis. The treatment involves applying Analytic Controls (pharmaceutical methods) and Clinical Controls, consisting of an initial phase (confirmation of the condition, duration and therapeutic level) and refinement of the prescription, patient information regarding the compatibility of drugs and precautions in the case of tooth extractions or surgery, and finally modification of the treatment in the event of complications (hemorrhage or thrombosis).

There are currently around 600,000 OAT patients in Spain, and this figure could grow at annual rates of up to 20% in the coming years.

The constant rise in the number of Oral Anticoagulant Treatment patients has resulted in:

• Overcrowding at hospitals:
  • Long patient waiting-lists
  • Pressure on hematology departments
  • An unavoidable reduction in the frequency of check-ups
• Patient problems in attending hospital control units
  • Low population density areas

It had become necessary to consider alternatives to decentralize OAT controls at both the Specialist and Primary Care levels by enabling self-medication by patients at home, in order to meet the increasing demand for treatment, relieve pressure on hospital hematology units and resolve patient access problems. Clearly, one of the keys to achieving these objectives would be to employ a Primary and Specialist Care information system to provide integrated control of the factors and data related with the process (patient medical records, analytical data and treatments related with OAT, socio-demographic data, etc.). At the time, however, no such information system existed.

To achieve the integration and management of the data generated at different control centers (Specialist Care, Primary Care and Self-Medication Patients) would be no easy task, in view of factors such as:

• The numerous solutions and differing IT strategies employed by health departments (Single Digital Medical Record). At the IT level, OAT was managed using are whole range of different alternatives and more or less complex models:
  • Isolated functioning at each treatment center based on PCs that were not connected to any other IT system, using commercial software for computerized management of OAT.
  • Isolated Systems with extension of the IT system. Each treatment had a terminal connected to the hematology laboratory via telephone, Internet, intranet…
  • Primary Care information system: In this case, the primary information system included an OAT management and control module, connecting each clinic to the system server via a corporate network.
• The hematology laboratories carrying out OAT monitoring tasks had a computerized support system.
• Primary care in the majority of Spain’s Autonomous Communities still had no IT support solution for the management of OAT, or if they did, the software was not integrated with the applications used at hematology units.
• Use of different data bases (Oracle, SQL Server, Informix, etc.).

Roche Diagnostics engaged Kynetia, a firm specializing in e-business technological developments, to design and develop a solution aimed at improving connection between patients and their doctors by integrating specialist and primary care systems. Kynetia was asked to provide integrated technological development services for the platform (christened “TAONet”) and connection via a range of supports and communication channels, including mobile phones, computers and PDAs, among others.

The Kynetia development would therefore have to be highly flexible to allow integration with any of the existing OAT management applications found at the levels of both specialist and primary care. TAONet would not require any change to working practices but would adjust to the existing work processes and patterns.

Furthermore, TAONet would need to be more than a mere data base and a series of processes to integrate different IT system, but would also be used as the final application used to manage the OAT treatment. Thus, it would need to include an OAT management application that could be set-up in line with the needs of different users (hematologists, primary care physicians, nursing staff, etc.). TAONet could, then, function as an OAT management software, while leaving the final decision about the use of this feature in the hands of the end user.

The solution

Technology
It was decided to develop TAONet using a Java-based technology (Java EE) for the business logic and XML (XML + XSLT) and HL-7 for integration. The use of open standards would allow TAONet to reside in multiple configurations and environments, ensuring the tremendous flexibility required for the system to provide optimum functioning in the numerous IT environments in use in Spanish hospitals.

Two further technologies were considered necessary 1) to improve the subjective experience of the end user, and 2) to enhance the flexibility of the platform. These were:

• Ajax – Until the development of TAONet, the medical software used in the management of Oral Anticoagulant Treatment usually consisted of desktop applications that did not refresh screens or involve waiting times. To avoid problems with users accustomed to applications of this kind, AJAX was used in the TAONet screens in order to mimic the screens displayed in desktop applications as far as possible.
• DAO patterns – Because TAONet was to be installed in a wide range of very different environments established by hospital / health area systems departments, the design employed a series of design patterns to allow adaptation to almost any operating environment. One of these patterns is DAO (Data Access Objects), allowing compatibility with any data base that supports JDBC without affecting the business logic of the application. This ensures that TAONet can be adapted to the specific needs of each installation. This matter is ever more important, because of health departments’ tendency to standardize, which makes it very difficult to install a new application if it is adapted to the environment.

Services and functionalities
The first TAONet installation was carried out at the Virgen de los Lirios Hospital in Alcoy (Alicante) in May 2005, and the application entered production immediately. Since then, demand for TAONet has grown continually, and by May 2007 it had been installed at some ten institutions throughout Spain (in Seville, Alicante, Logroño, Calahorra, Alcoy, Soria, Úbeda, Salamanca,…) and was serving over 80 users. Forecasts for 2008 are for a further increase in these figures, and TAONet is already in the process of implementation by the Castile-La Mancha (SESCAM) and Extremadura (Servicio Extremeño de Salud) health services.

The TAONet platform developed by Kynetia for Roche provides the following services and functionalities, among others:

• Integration with all Hospital, Laboratory and Health Center systems.
• Centralization of patient data, allowing the decentralization of treatment and the use of different patient management models.
• Use of the HL7 (Health Level 7) standard, a protocol developed specifically for public healthcare environments, as a channel for integration in the medical / pharmaceutical sector.
• Standards-based design, allowing installation in almost any operating environment (hardware, operating system, applications server, web server and data base server).
• Localization service allowing international implementation of the solution.
• Delivery of alerts over a range of channels (fax, e-mail, SMS), and integration with a voice portal.

Because it is a mission-critical platform (manages treatment dosages, among other functions), and nationwide deployment multiplied the number of users, it became necessary to:

• Provide the implementation areas with the support necessary to undertake the installation, integration and launch of the platform.
• Provide support for the system’s users from training through to daily operation.
• Perform evolutionary maintenance work on the platform in line with the needs of each roll-out environment.

Benefits of TAONet

In addition to eliminating redundancy in data inputs, thereby shortening response times and lowering the number of errors, TAONet ensures better quality care for patients and improves OAT management by physicians and nursing units. The system offers the following key benefits:

Patients

• Significant reduction in check-up waiting times, because of the increase in the number of clinics and hospitals able to handle to the process.
• Reduction in waiting times because the processes required to determine INR and dosages have been speeded up.
• Possibility of more frequent OAT check-ups, allowing better monitoring of each patient’s pathology and a lower risk of medical complications.
• TAONet allows self-medication by patients, including a module permitting management of all data generated over the individual’s self-medication cycles.

Health professionals

• Access to a single data base providing real time access to patient data from any healthcare facility.
• Easy coordination between Primary and Specialist Carers, improving patient monitoring.
• Creation of a single set of regional healthcare statistics.
• Flexible adaptation to existing information systems and working methods, because TAONet integrates with but does not change existing processes.

Public health managers

• Elimination of redundancies in data inputs, saving time in patient management procedures.
• Reduction in errors for the same reason.
• Generation of data for use in medical studies (R&D), sociological research, etc.
• Model for future action in the delivery of other types of medication and the management of patients suffering other diseases.