CASE
Mountain View Community Hospital
IntroductionThis case is included to provide you an opportunity to apply the concepts and techniques you will learn in each chapter. The case can also be used to support a semester-long database proj-ect built throughout the term that results in a complete applica-tion. We have selected a hospital for this case because it is a type of organization that is at least somewhat familiar to most per-sons and because health-care institutions are of such impor-tance in our society today. A segment of the case is included at the end of each chapter in this text. Each segment includes a brief description of the case as it relates to the material in the chapter followed by questions and exercises related to the mate-rial. Additional requirements, assignments, and project deliver-ables are provided in support of a semester project.
Case Description
Mountain View Community Hospital (MVCH) is a not-for-profit, short-term, acute care general hospital. It is a relatively small hos-pital, with some 150 beds. Mountain View Community Hospital strives to meet the needs of a community of about 60,000 with an annual growth rate of 10 percent, a trend that is expected to con-tinue since the surrounding area is attracting many retirees. To serve the health-care needs of this growing community, Mountain View Community Hospital plans to expand its capacity by adding another 50 beds over the next five years, and opening a managed care retirement center with independent apartments and assisted living facilities. The basic goal is to provide high-quality, cost-effective health-care services for the surrounding community in a compassionate, caring, and personalized manner.
Within the last fiscal year, the hospital performed more than one million laboratory procedures and over 110,000 radiol-ogy procedures. During that time, the hospital had 9,192 admis-sions and 112,230 outpatient visits, brought 1,127 babies into the world, and performed 2,314 inpatient and 1,490 outpatient sur-geries. Patients who receive outpatient surgeries do not remain in the hospital overnight. With an average of 2,340 patients a month, the emergency department experienced approximately 28,200 visits throughout the year. Approximately 30 percent of the patients admitted to the hospital were first treated in the emergency room, and about 13 percent of emergency room vis-its resulted in hospital admission. The hospital employs 740 time and 439 part-time personnel, among them 264 full-time and 176 part-full-time registered nurses, and 10 full-full-time and 6 part-time licensed practical nurses. The hospital’s active med-ical staff includes over 250 primary physicians, specialists, and subspecialists. Volunteers are an integral part of MVCH’s cul-ture and contribute greatly to the well-being of patients and their families. Approximately 300 volunteers from different backgrounds and of all ages devote their time, energy, and tal-ents to many areas of the hospital. They greet visitors and pa-tients and help them find their way through the hospital, deliv-er mail and flowdeliv-ers to patient rooms, escort patients, aid staff with clerical duties, work in the gift shop, assist at community and fund-raising events, and help out in a host of other areas. Mountain View Community Hospital provides a number
general intensive care, a cardiology department, open-heart surgery, a neurology department, pediatric medical and surgi-cal care, obstetrics, an orthopedics department, oncology, and a 24-hour emergency department. The hospital also offers a wide range of diagnostic services. A specialty service within the neu-rology department is the recently opened Multiple Sclerosis (MS) Center, which provides comprehensive and expert care for patients with multiple sclerosis in order to improve their quali-ty of life. Using an interdisciplinary team approach, the center emphasizes all aspects of MS care from diagnosis and treatment of MS symptoms and secondary complications, to individual and family counseling, rehabilitation therapy, and social servic-es. Headed by Dr. Zequida, called Dr. “Z” by staff and patients, the MS Center is a member of a consortium of MS centers.
The current organizational chart for Mountain View Community Hospital is shown in MVCH Figure 1-1. Like most other general hospitals, Mountain View Community is divided into two primary organizational groups. The physicians, headed by Dr. Browne (chief of staff), are responsible for the quality of medical care provided to their patients. The group headed by Ms. Baker (CEO and president) provides the nurs-ing, clinical, and administrative support the physicians need to serve their patients. According to Ms. Baker, the most press-ing issues affectpress-ing the hospital within the last year have been financial challenges such as bad debt, personnel shortages (particularly registered nurses and imaging technicians), and malpractice insurance. Other critical issues are the quality of care, patient safety, compliance with HIPAA, and technologi-cal innovation, which is seen as a major enabler for decreasing costs and improving quality. The trend toward managed care and the need to maintain costs while maintaining/improving clinical outcomes requires the hospital to track and analyze both clinical and financial data related to patient care services. Goals and Critical Success Factors
In response to the steady growth and expansion plans at Mountain View Community Hospital, a special study team in-cluding Mr. Heller, Mr. Lopez, Dr. Jefferson, and a consultant has been developing a long-term strategic plan, including an in-formation systems plan for the hospital. Their work is not com-plete, but they have begun to identify many of the elements nec-essary to build the plan. To meet the goals of high-quality health care, cost containment, and expansion into new services, the team concluded that the hospital has four critical success factors (CSFs): quality of medical care, control of operating costs, con-trol of capital costs, and recruitment and retention of skilled personnel. The development of improved information systems is viewed as an enabler in dealing with each of these CSFs.
The team is currently at work to generate two to four short- or long-term objectives for each CSF. So far they have developed the following four objectives related to the control of the operating costs CSF:
1. Reduce costs for purchased items 2. More efficiently schedule staff 3. Lower cost of liability insurance
The study team has developed a preliminary list of busi-ness functions that describe the administrative and medical activities within the hospital. These functions consider the or-ganizational goals and CSFs explained in the prior section. At this point, the study team has identified five major business functions that cut across all of the organizational units:
1. Patient care administration Manage the logistical and record-keeping aspects of patient care
2. Clinical services Provide laboratory testing and proce-dures, and patient monitoring and screening
3. Patient care services Provide patients with medical care and support services
4. Financial management Manage the financial resources and operations of the hospital
5. Administrative services Provide general management and support services not directly related to patient care
The study team has been able to break each of these high-level business functions into lists of more detailed functions (see MVCH Figure 1-2), but the team knows that these lists are not complete nor well defined at this point.
Mountain View Community Hospital has computer applications that support the following areas (among others): patient care administration, clinical services, financial manage-ment, and administrative services. Many of these applications have been purchased from outside vendors, but a few have been developed internally. Most of the computer applications are implemented using relational database and client/server technology. In the client/server environment, the client runs the database applications that request the data. The server runs the DBMS software, which fulfills the requests and handles the functions required for concurrent, shared data access to the database. Most of the databases (as well as the applications) are two tier, using the classification introduced in this chapter.
Patient care Patient care Financial Administrative
administration Clinical services services management services
Patient scheduling Patient registration • Admit patient • Assign patient to bed • Transfer patient • Discharge patient Physician orders Laboratory reporting Electrodiagnosis Psychiatric testing Patient monitoring Multiphasic screening Radiology • Perform X-rays Laboratory • Perform blood tests
Dietary/Nutrition Nursing Surgery Rehabilitation
• Perform physical therapy Blood banking
Patient accounting • Bill patient
• Account for receivables Cost accounting Payroll General accounting Risk management Purchasing Inventory control Housekeeping Personnel Volunteering • Recruit volunteers • Schedule volunteers • Evaluate volunteers
MVCH FIGURE 1-2 Business functions
Board of Directors Ms. Baker CEO Dr. Browne Chief of Staff Ms. Price VP Clinical Services Mr. Heller CIO Mr. Thomas Spiritual Care Mr. Lopez Chief Financial Officer Ms. Alvarez Accounting Ms. Baddeck Chief Administrative Officer Mr. Davis Volunteer Services Mr. Clay Admissions & Patient Accounts Ms. Crowley Assistant Dr. Redfern Chief of Medicine Dr. Jefferson Chief of Surgery Ms. Stevens Personnel Ms. Knight Chief Nursing Officer
MVCH FIGURE 1-1 Organizational chart
Enterprise Modeling
The study team identified a preliminary set of 11 entity types that describe the data required by the hospital in support of the various business functions: FACILITY, PHYSICIAN, PATIENT, DIAGNOSTIC UNIT, WARD, STAFF, ORDER, SERVICE/DRUG, MEDICAL/SURGICAL ITEM, SUPPLY ITEM, and VENDOR. From discussions with hospital staff, reviewing hospital docu-ments, and studying existing information systems, the study team developed a list of business rules describing the policies of the hospital and nature of the hospital’s operation that govern the relationships between these entities. Some of these rules are: 1. A FACILITY maintains one or more DIAGNOSTIC UNITS (radiology, clinical laboratory, cardiac diagnostic unit, etc.). 2. A FACILITY contains a number of WARDs (obstetrics,
on-cology, geriatrics, etc.).
3. Each WARD is assigned a certain number of STAFF mem-bers (nurses, secretaries, etc.); a STAFF member may be assigned to multiple WARDs.
4. A FACILITY staffs its medical team with a number of PHYSICIANs. A PHYSICIAN may be on the staff of more than one FACILITY.
5. A PHYSICIAN treats PATIENTs, and a PATIENT is treat-ed by any number of PHYSICIANs.
6. A PHYSICIAN diagnoses PATIENTs, and a PATIENT is diagnosed by any number of PHYSICIANs.
7. A PATIENT may be assigned to a WARD (outpatients are not assigned to a WARD). The hospital cares only about the current WARD a patient is assigned to (if assigned at all). 8. A PATIENT uses MEDICAL/SURGICAL ITEMS, which are supplied by VENDORs. A VENDOR also provides SUPPLY ITEMs that are used for housekeeping and main-tenance purposes.
9. A PHYSICIAN writes one or more ORDERS for a TIENT. Each ORDER is for a given PATIENT, and a PA-TIENT may have many ORDERs.
10. An ORDER can be for a diagnostic test (lab tests such as lipid profile, CBC, liver function tests; diagnostic imaging such as MRIs and X-rays) or a drug.
They recognized that certain business functions, such as risk management and volunteering, were not adequately repre-sented in the set of data entities and business rules, but they de-cided to deal with these and other areas later. The study team stored descriptions of these data entities and the business rules in the CASE repository for later analysis. Using the identified entities and business rules, the study team developed a prelim-inary enterprise data model (see MVCH Figure 1-3). Again, this conceptual model is preliminary and does not follow all the conventions used in the information systems department for drawing data models, but the purpose of this enterprise model is to give only a general overview of organizational data. Case Questions
1. The goal of Mountain View Community Hospital is to pro-vide high-quality, cost-effective health-care services for the surrounding community in a compassionate, caring, and personalized manner. Give some examples of how the use of databases in the hospital might improve health-care quality or contain costs. How else could a well-managed database help the hospital achieve its mission?
2. How can database technology be used to help Mountain View Community Hospital comply with the security stan-dards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)? HIPAA requires health-care providers to maintain reasonable and appropri-ate administrative, technical, and physical safeguards to ensure that the integrity, confidentiality, and availability of electronic health information they collect, maintain, use, or transmit is protected. (For more details on HIPAA, visit www.hhs.gov/ocr/privacy.)
3. What are some of the costs and risks of using databases that the hospital must manage carefully?
4. How critical are data quality requirements in the hospital environment? For which applications might quality re-quirements be more restrictive?
5. At present, Mountain View Community Hospital is using relational database technology. Although this technology is
Is Assigned To Uses FACILITY WARD Contains PHYSICIAN PATIENT MEDICAL/ SURGICAL STAFF SUPPLY ITEM VENDOR ORDER TEST/ DRUG Diagnoses Treats Staffs Is For Is Written By Works At Is Provided By Is Supplied By Is Given To MVCH FIGURE 1-3 Preliminary enterprise data model
appropriate for structured data, such as patient or account-ing data, it is less well-suited to unstructured data, such as graphical data and images. Can you think of some types of data maintained by a hospital that fit this latter category? What types of database technology rather than relational might be better suited to these data types?
6. How could the hospital use Web-based applications? What are some of the benefits and risks associated with Web-based applications for the hospital?
7. The case description lists 10 business rules. The study team used these rules to develop MVCH Figure 1-3. Are there any other business rules implied by or depicted in that fig-ure? What are they?
Case Exercises
1. The relational databases at Mountain View Community Hospital contain a number of tables. Two of these tables, with some sample data, are shown in MVCH Figure 1-4. The PATIENT table contains data concerning current or re-cent patients at the hospital, whereas the PATIENT CHARGES table contains data describing charges that have been incurred by those patients. Interestingly, the PATIENT CHARGES table is not captured in the preliminary enter-prise data model shown in Figure 1-3.
a. Using the notation introduced in this chapter, draw a di-agram showing the relationship between the entities PATIENT and PATIENT CHARGES.
b. Develop a metadata chart for the data attributes in the PATIENT and PATIENT CHARGES tables using (at minimum) the columns shown in Table 1-1. You may in-clude other metadata characteristics that you think are appropriate for the management of data at Mountain View Community Hospital.
2. One of the important outputs from the “bill patient” busi-ness function is the Patient Bill. Following is a highly sim-plified version of this bill (MVCH Figure 1-5).
a. Using the data from MVCH Figure 1-4, add missing data that would typically appear on a patient bill. b. Using your result from part a), verify that the enterprise
data model in MVCH Figure 1-3 contains the data nec-essary to generate a patient bill. Explain what you have to do to perform this verification. What did you discov-er from your analysis?
3. Using the notation introduced in this chapter, draw a single diagram that represents the following relationships in the hospital environment.
• A HOSPITAL has on its staff one or more PHYSICIANs. A PHYSICIAN is on the staff of only one HOSPITAL. • A PHYSICIAN may admit one or more PATIENTs. A
PA-TIENT is admitted by only one PHYSICIAN.
• A HOSPITAL has one or more WARDs. Each WARD is lo-cated in exactly one HOSPITAL.
• A WARD has any number of EMPLOYEEs. An EMPLOY-EE may work in one or more WARDs.
4. Using a DBMS suggested by your instructor, such as Microsoft Access or SQL Server, you may begin to prototype a database for Mountain View Community Hospital. Here are some suggestions to guide you:
a. Develop a metadata chart for an EMPLOYEE table simi-lar to Table 1-1.
b. What types of relationships (1:1, 1:M, or M:N) are likely to exist between your PATIENT table and other tables in the database? How did you determine that?
c. MVCH hospital administrators regularly need informa-tion about their patient populainforma-tion. Based on the distinc-tion between data and informadistinc-tion discussed in this
PATIENT Patient Number 8379 4238 3047 5838 6143 Dimas Dolan Larreau Wiggins Thomas
Patient Last Name
Selena Mark Annette Brian Wendell
Patient First Name
617 Valley Vista 818 River Run 127 Sandhill 431 Walnut 928 Logan Patient Address PATIENT CHARGES Item Description Room Semi-Priv Speech Therapy Radiology Physical Therapy EKG Test Room Semi-Priv Standard IV EEG Test 200 350 275 409 500 200 470 700 Item Code 4238 3047 4238 5838 8379 3047 8379 4238 Patient Number 1600 750 150 600 200 800 150 200 Amount MVCH FIGURE 1-4 Two
database tables from Mountain View Community Hospital
chapter, explain why a printout of a PATIENT table will not satisfy these information needs.
d. Create a report that organizes the data from your PA-TIENT table to provide hospital administrators with use-ful information about the patient population at MVCH. 5. Earlier in this chapter, we showed an SQL query that dis-plays information about computer desks at Pine Valley Furniture Company:
SELECT * FROM Product
WHERE ProductDescription=“Computer Desk”; Following this example, create an SQL query for your PA-TIENT table that displays information about the outpatients. 6. The manager of the risk management area, Ms. Jamieson, is anxious to receive computerized support for her activities. The hospital is increasingly facing malpractice claims and lit-igation, and she does not believe she can wait for improved information services until the information systems and data-base plans are set. Specifically, Ms. Jamieson wants a system that will track claims, legal suits, lawyers, judges, medical staff, disbursements against claims, and judgments. How would you proceed to deal with this request for improved information services? What methodology would you apply to design or acquire the systems and databases she needs? Why?
7. Consider again the request of the manager of risk manage-ment from Case Exercise 6. On what tier or tiers would you
recommend the system and database she needs be devel-oped? Why?
Project Assignments
P1. The study team’s activities described in this case study are still in the very early stages of information system and database development. Outline the next steps that should be followed within the Information Systems unit to align current systems and databases to the future information systems needs of the hospital.
P2. The patient bill is an example of a view that would be of in-terest in a hospital environment. Identify and list other user views that could occur in a hospital environment.
P3. Carefully read through the case description, exercises, and questions again and:
a. Modify the enterprise data model shown in MVCH Figure 1-3 to include any additional entities and rela-tionships that you identify.
b. Modify the list of business rules from the case descrip-tion to include the addidescrip-tional entities and reladescrip-tionships you identified.
c. Draw a context diagram of MVCH’s improved informa-tion system similar to the one for a burger restaurant shown in MVCH Figure 1-6. A context diagram pro-vides the highest-level view of a system and shows the system boundaries, external entities that interact with the system, and major information flows between the entities and the system.
Patient Name: Dolan, Mark Patient Number:
Patient Address:
Item Code Item Description Amount
MVCH FIGURE 1-5 Partial patient bill Food Ordering System CUSTOMER Customer Order RESTAURANT Management Reports Receipt KITCHEN Food Order MVCH FIGURE 1-6 Context diagram example
Source: Adapted from Hoffer et al. (2010).
