EHR: Best of Breed Losing Ground to Integrated Aps

Information technology, even in small doses, can boost productivity for many businesses. But large hospitals and health systems seem to get the most bang for the buck from  enterprise-wide IT strategies that knit together clinical and administrative areas, say a few leading hospital CIOs and CMOs.

Take, for example, CareGroup Health System in the Boston area, which includes Beth Israel Deaconess Medical Center, Mount Auburn Hospital, and New England Baptist Hospital. CareGroup has 3,000 affiliated physicians, serving a patient base of 9 million. The health-IT infrastructure sends a staggering 100 terabytes worth of data and images from its electronic medical record and other information systems across 22,000 network nodes each day.

"The tolerance clinicians have for downtime is zero," says John Halamka, M.D., chief information officer of both CareGroup and Harvard Medical School in Boston. "We're all Web-connected. We expect information instantly," says Halamka, who also practices emergency medicine at Beth Israel Deaconess.

"You build a world-class infrastructure so you can change the wings of a 747 while it's flying," Halamka adds. CareGroup's data backbone is down an average of 8 minutes per year, including planned downtime. "That's what an enterprise expects," he says. An enterprise-wide IT strategy helps sort out complex tasks.

Perhaps not surprisingly, the desire to achieve enterprise-wide connectivity has many health-IT executives winnowing down their supplier bases and choosing integrated products over narrower, best-of-breed offerings, at least at large facilities. Everything must work together or the hoped-for productivity boom quickly busts.

William F. Bria had such an experience while he was the chief medical information officer at the University of Michigan Health System leading Y2K preparations. After identifying more than 400 different clinical applications running across the network, Bria's team decided to consolidate by creating a single clinical data repository rather than overhaul all of the disparate software, solving the problem of integrating clinical systems.

The mix of commercial to home-grown software was about 50/50 and included applications such as Pathnet, ADAC, McKesson Patient Management, and WorX, says Bria, who culled out many duplicative applications. The big winners, he says, are the clinicians who could "one stop shop" for all patient information and content spanning the continuum of care, rather than approaching just inpatient/outpatient as traditional EMRs had done. 

"It transformed the discussion from system integration to data integration," he recalls. The new system, CareWeb, is now available at all of the health system's more than 30 hospitals and clinics.

"We [also] used the system to enforce standards of practice," he says. The state of Michigan has a registry for child vaccinations, and CareWeb helped university physicians achieve more than 90 percent compliance, Bria says. "It became a lot easier to translate the daily operations of patient care into reports."

Bria, who left Ann Arbor earlier this year, says that one physician at Michigan who reviewed some electronic records discovered the cardiology department was not billing properly, and was able to recoup several million dollars in revenue that otherwise might have slipped through the cracks.

Bria has since taken his expertise to the Tampa, Fla., headquarters to Shriners Hospitals for Children, where he manages information across 22 hospitals from coast to coast and beyond, in a system that stretches from Montreal to Mexico City and Honolulu.

Shriners is the largest charity health system in the country, focusing on pediatric burn care and pediatric orthopedics, so it operates almost like a network of specialty hospitals. Bria faces a challenge in coordinating the flow of information across five time zones, and it is impractical for him to go to each site to lead an IT rollout, and then repeat the process for system upgrades.

"the time you visit all of these, it would be two years, and then you'd have to start again," he says. So Shriners operates like an application service provider, serving all hospitals out of a single data center in Florida. "Whatever is going on in Tampa is also going on in Sacramento, is also going on in Honolulu," Bria says. "This is a child of the new Information Age."

For a large, integrated health system to take full advantage of IT, Bria believes that the approach should be to leverage patient care and data warehousing for improvements across the board. "It's our 'A-ha!," he says.

Bria, who is president of the Association of Medical Directors of Information Systems, views information flow as a triangle. From the patient visit at the top of the triangle, results and orders enter into the continuum of care for a single patient. An integrated electronic health record connects the individual's continuum with the continuum of care for all similar patients, which, in turn, creates clinical decision support to inform clinicians for the patient visit.

He calls the continuum for patients with like conditions "the big deal," because it facilitates medical and financial benchmarking, allowing for a better assessment of which interventions work for a particular condition and which do not. "Ultimately, the decision support is the data of the environment," Bria says.

For the medical staff, this information shows how each facility is performing overall and if the hospital is implementing necessary changes. "There is no such thing as one size fits all in medicine," Bria says.

"What your particular group needs," he continues, "you have to find that out yourself. There's nothing other than an information system that can do that."

Steve Margolis is working toward finding such answers as chief medical information officer of Orlando Regional Healthcare, an eight-hospital system in central Florida. "We're busy at this stage trying to get clinical documentation at all of our hospitals," says Margolis, who joined Orlando Regional two years ago to lead an EHR implementation program.

Physicians now can view images from outside the hospitals, but they do not have remote electronic clinical documentation yet. "They haven't done away with paper charts yet," Margolis says.

"We're looking to do real-time documentation," Margolis explains. This he says, will reduce transcription expenses, enable faster bed turnaround, and move patients out of harmful, germ-filled environments as quickly as possible.

The stakes could not be higher. "The board is absolutely expecting this to help us comply" with various accreditation and care standards, Margolis says.

Plenty of work remains, however. Orlando Regional is in the difficult position now of running dual, parallel electronic and paper systems. "It's very aggravating for some people," Margolis says. The situation is temporary, but the CMIO first must untangle a hodgepodge of health-IT systems put in place before he took over.

Orlando Regional has chosen Eclipsys as its preferred technology vendor, and is updating its pharmacy systems with that company's software. Most of the hospitals already are running Eclipsys EMRs.

But the rest of the IT infrastructure is a collection of products, including an Affinity registration system, Allscripts ambulatory EMR, and various components from Misys Healthcare Systems. McKesson and predecessor company HBOC provide cardiac picture archiving and communication systems (PACS) and the old pharmacy systems, while GE Healthcare is the PACS vendor for all other departments.

"We'd like one vendor where possible," Margolis says. "The more interfaces we have to write, the more difficult it is."

Vendors are noticing a pronounced shift in the health-IT market to a single-vendor approach from the previously popular best-of-breed strategy of picking and choosing technology components from multiple suppliers.

"It's interesting how they go back and forth between best of breed and enterprise," notes Parixit Joshi, a senior project manager at Misys. Reflecting this decade's trend, Misys represents the 2002 consolidation of Medic Computer Systems, Sunquest Information Systems and Home Care Information Systems. Other companies, notably GE Healthcare, have combined inpatient, ambulatory, management, and financial systems under a single banner in recent years.

Misys is emphasizing tighter links between its inpatient and ambulatory technologies by interspersing some hospital-focused people among the outpatient division at corporate headquarters in Raleigh, N.C., even though the Hospital Systems division is based in Tucson, Ariz. Sales teams have started collaborating as well. "Our sales folks have coordinated and done presentations together," Joshi says.

Scheduling is as much a part of the enterprise system as the EHR itself. "We feel it's very tied into the clinical event," Joshi says. Before a surgery, for example, certain tests have to be completed, and an integrated system can make sure everything happens in proper sequence, without having to wait for manual reporting.

"We don't think you can separate the two," says Joshi. "With our customers, we highly, highly recommend that they do not install one without the other."

Another key element of an enterprise-wide IT strategy is data storage, particularly for someone like Halamka in Massachusetts, a state that requires medical records to be kept for 30 years.

A single mammogram takes up 100 MB of disk space, according to Halamka. If a mammogram shows no major health issues, it can be archived, but if the patient has a condition requiring treatment, the image has to be readily accessible. "You buy different classes of hardware for storage based on the importance of the information," he says.

And yet the paper continues to pile up. "Even though we are 85 percent electronic, we still add 15 inches of paper to our warehouse every night," Halamka says.

Halamka is looking at the possibility of digitizing and indexing paper that comes in from outside the CareGroup institutions, but he wants actual, usable data, not just scanned images.

Fortunately, the network architecture is already prepared to sort the information, thanks to a master patient index that points to every record in the system, no matter where the information is stored. A Web link lets users pull up information as needed and view it in the browser. "We centralize the index but leave data where it's natively created," Halamka says.

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