Context management

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Context Management is a dynamic computer process that enables data elements pertaining to a specific subject to be maintained when switching between applications. Once a user selects a subject within one application, context management “activates” the same subject when other applications are opened. Context management enables a clinician to select a particular patient in one healthcare application and then open other applications with that patient already selected. Not only does this improve workflow efficiency, it also improves safety by insuring that the clinical data being collected from different applications pertain to the same patient.


Context management provides benefit for healthcare organizations that utilize a collection of healthcare applications from different vendors that don’t interface or exchange data to a significant extent.

Context management can be used in conjunction with single sign on (SSO) to further improve workflow efficiency. Single sign-on (also known as Enterprise Single Sign On or ESSO) is a property of access control of multiple, related, but independent software systems. The enterprise network and the healthcare applications contained within the network all may require different usernames and passwords. Further, requirements for password content and frequency of change may differ among applications. Single sign on allows the user to enter one username/password, which then grants access to multiple applications within the system. SSO may grant access to all applications, or if additional layers of security are deemed necessary, SSO may only grant access to a subset of applications with additional authentication methods being required for access to other applications.


CCOW is a vendor independent HL7 standard that enables context management when switching between different clinical applications. CCOW works for both client-server and web-based applications.


CCOW stands for "Clinical Context Object Workgroup", the committee within the HL7 group that developed the standard. The goal of CCOW is to create a clinical user’s experience of interacting with a single system, when the user is actually using multiple, independent applications from many different systems.

Contexts that can be shared by CCOW include patient (name and identifying numbers), user, and encounter.

CCOW context management architecture has three main components

  1. Clinical applications (context participants)
  2. Context manager to coordinate and synchronize the applications
  3. Mapping agents to map equivalent identifiers, allowing applications to interoperate without sharing the same identification method for a particular patient or user.

Components can communication via Web (HTTP) or ActiveX mapping, which allows interoperability between applications using different technologies.

Advantages of CCOW

  1. Greater purchasing flexibility. Since CCOW enables widespread interoperability, institutions can choose and implement the clinical applications that meets their particular needs, regardless of vendor.
  2. Rapid, unified access to patient data from different applications helps insure an efficient workflow environment for end-users.
  3. Single sign-on management improves workflow efficiency and end-user satisfaction.
  4. Context oriented workflow improves both efficiency and safety.
  5. Existing software investment is leveraged by enabling context management in applications already in use.

Disadvantages of CCOW

  1. A “certified” CCOW compliant application may not offer true CCOW interoperability
  2. An organization may have applications already in use that are not CCOW compliant.
  3. CCOW requires a “fat client” on each workstation. This could be problematic when some users sign in from outside facilities such as clinic offices.
  4. Requires server side crosswalk table for application login password adjudication


Global Session Manager is a commercial (Siemens) portal that enables both single sign-on and context management. It allows developers to create Java based procedures to implement integrated workflow between applications. With GSM one application (parent) designates the context for other applications (child), as compared with CCOW, in which any application can designate the context.

Advantages of GSM

  1. No need for “fat client” on each workstation since it is coded on the application.
  2. Can use Java toolkit to create code for other applications.
  3. Do not need to sign-on to domain network before opening applications.
  4. May require less complicated architecture and development time than CCOW to implement.
  5. Does not require server side crosswalk table for passwords.
  6. Signing off “parent” application closes all other open GSM applications.

Disadvantages of GSM

  1. Requires one application to be designated as “parent”. This cannot be changed once programmed.
  2. Requires code to be added to all applications.
  3. Certain applications, such as CPOE, do not allow free movement between applications.

Other examples of commercial Vendors that supply single sign-on and context management solutions

  1. Sentillion
  2. Carefx Fusion
  3. IBM Tivoli Encenuate
  4. Imprivata
  5. Novell


Berger RG and Baba J. The realities of implementation of Clinical context Object Workgroup (CCOW) standards for integration of vendor disparate clinical software in a large medical center. Int J Med Inform. 2009; 78:386-390.

Submitted by Barry Perlman