In the battle between best-of-breed versus whole enchilada philosophy, there is no clear knock-down -- at least not yet.

“The issue with best-of-breed is integration,” notes James Hereford, executive vice president for strategic services and quality at Group Health Cooperative of Puget Sound, Seattle.

Craig Safir, marketing director at Kansas City, Mo.-based health-IT vendor Cerner, frames the debate in terms of modality. “I think folks are seeing that an integrated solution is the way to go within the four walls,” he says. “The battleground is outside the four walls.”

He suggests that health systems ought to consider consumer attitudes. “They want their retail pharmacies to know their allergies,” Safir says. They want the Minute Clinic at the Walgreens to know the patient’s history he suggests. Safir believes the time is right to take a systems-oriented view beyond the hospital and out into the community.

Not so fast, says Dan Mingle, assistant medical director at MaineGeneral Medical Center, Augusta, Maine. He is absolutely sold on the best-of-breed idea in which healthcare providers choose the most relevant components of health-IT systems, from however many suppliers necessary, to suit their own needs and integrate the parts into a workable whole.

“It’s easy to get out of the realm of a single vendor once you look at scaling,” Mingle says. This is true no matter if it’s an electronic medical record, a financial system, or even e-mail software. Mingle certainly is looking at scaling. He is the principal investigator for a three-year, $1.5 million grant from the federal Agency for Healthcare Research and Quality, awarded in 2005, to build an interoperable ambulatory electronic health record for a seven-county region in Maine.

MaineGeneral has an Eclipsys inpatient EMR, but the hospital network chose Allscripts for ambulatory care both in-house and to offer to any participating independent practices that might be interested.

One factor in the selection of Allscripts for the grant-funded network, says Mingle, was that its TouchWorks EMR for large physician groups and HealthMatics, the former A4 Healthcare Systems product for smaller practices that Allscripts acquired last year, both interface with the IDX Group Practice Management System, which has long been popular in central Maine.

Moreover, with the possibility that more than 100 practices will want to join the community EHR project, there are bound to be more than a few using different products. “There are probably a dozen different practice management systems in the 112 practices that we potentially will serve in our market,” Mingle says. “At this time, our intention is to take all comers.”

That strategy, combined with the new exemptions to the Stark and Medicare anti-kickback rules that allow hospitals to cover up to 85 percent of software costs for physician practices to purchase interoperable EHRs, will keep systems integrators busy in the foreseeable future.

“We’re starting to see some interest in this approach to give EHRs to small and rural practices,” Mingle says. That provides a single platform for participants, but, Mingle notes, “Now we’re seeing that EHRs can be community health networks across [provider] networks.” Once you start drawing in entities with their own technology, one vendor cannot possibly fit all.

“It becomes harder to have a single source. You become agnostic,” Mingle says.

Allscripts’ answer for  MaineGeneral and others purusing best-of-breed strategies has been to simplify integration  with the so-called Universal Application Integrator (UAI). Allscripts describes the innovation as a “USB for health.” It’s not exactly that, since USB is a hardware standard, while the UAI is software that allows for easy connection of health-IT software components, but the point is well taken.

The UAI essentially is specialty code for integrating Allscripts’ TouchWorks and HealthMatics EHRs with scores of medical devices and software applications. “We take that expertise and integrate it into our system,” explains UAI developer Stanley Crane, chief technology officer at Allscripts.

Crane emphasizes the purpose of the UAI is to “integrate, not interface.” It can “open the door to brilliant little pieces of technology,” he says.

For example, Allscripts is offering an oncology component from Smart ID Works, an Ada, Mich.-based seller of specialty practice management software, as part of the newest version of TouchWorks. Elsewhere, a psychology practice has asked Allscripts to add an inventory of depression-related information to a standard EHR, Crane reports. For hospital or postoperative care, the UAI can integrate data from vitals monitors into the clinical record.

Crane’s team has to build each connection only once. “We can do all sorts of wonderful things once that’s dropped into our database,” he says. “Part of UAI is the ability to say yes faster” when customers ask about integrating a component.

Crane says he personally believes that the future may see some companies selling only hybrid-type systems, but Allscripts has not announced such plans.

The thinking at Cerner seems quite different. It markets a full selection of inpatient and outpatient systems. Of note, Cerner introduced a line of medical devices last year that integrate with clinical information systems in an attempt to give hospital clients a single place to go to find information. Interoperability, not surprisingly, is built in.

“Fundamentally, we think that a lot of medical devices on the market today, they try to be too smart or they’re too dumb,” says Safir of Cerner. This means that either the devices don’t connect to anything or “they’re trying to replicate some notion of an EMR or record that is isolated from the clinical context of the patient,” Safir says.

Safir says potential customers should consider a single source for reasons of quality, cost, and clinician workflow. With multiple vendors, it’s possible to achieve those goals with a single sign-on, but that technology cannot cover every piece.

Even Safir admits, “There is no hospital in the world that’s a pristine Cerner environment.” And there may not be anytime soon, which is why he and the company are promoting unification of databases.

“We believe [in] a single database for inpatient and outpatient venues,” Safir says. “That is the way to optimize the clinical environment.  I think the market continues to vote toward a single-database approach. It’s really a move to a single source of truth.”

The presence of a constant link from device to EMR can help clinicians measure change in a patient’s trajectory. “Making that information in real time is really important to our clients,” Safir says. “It’s providing the clinical context for the data.”

He also says a single database that connects clinical and management information can provide financial benefits in terms of hospital asset management, in a manner that is much less expensive than a newer technology like radio-frequency identification.

“If you’re integrated at the database level, you can really manage information from end to end,” says Group Health’s Hereford. “What it forces is a tighter level of workflow when you have a common platform.” This is good for quality control and measurement of outcomes. “It certainly makes it easier to get the data,” he says.

Group Health, which is loosely affiliated with the Kaiser Permanente organization, falls squarely into the single-source camp. “We certainly look at suite solutions and build around that,” Hereford affirms.

In late 2001, Group Health decided to go with an Epic Systems EHR and management package for ambulatory care, more than a year before Kaiser chose the same vendor for its nationwide operations. The first installation went live in the fall of 2003, and the rollout took two years.

Even with a primary vendor, some degree of interfacing and integration is necessary. Though Group Health is replacing an IDX hospital information system with an Epic product, the current Philips Medical Systems picture archiving and communication system (PACS) is staying put, since Madison, Wis.-based Epic does not offer its own PACS, nor does Epic have an outpatient pharmacy system. “Even with a large footprint of Epic, we still have a lot of interfacing,” Hereford says.

Interfacing is almost a thing of the past at Washington Hospital Center in the nation’s capital, an affiliate of seven-hospital MedStar Health (Columbia, Md.)., since the facility is home to the developers of data-integration engine Azyxxi.

Washington Hospital Center alone has hundreds of information systems. “We came down on the side of best-of-breed and integrating data,” says emergency medicine chief Mark Smith, co-creator of Azyxxi. MedStar sold Azyxxi to Microsoft last fall (see “Microsoft Acquires Healthcare Software”), and that company currently is modifying the software for commercial purposes.

The idea for the integrator dates to the late 1980s. “We made observations about how clinicians spend their time. Twenty, 30, 50 percent of their time they were looking for data,” Smith says. “The strategy we chose was to liberate the data from the system that created it.”

That led to the creation of the Azyxxi database, a single repository for the entire hospital. The design facilitates transformation at three points: data storage, retrieval, and viewing, according to Smith. “Our philosophy is that storage is cheap,” Smith says.

Such architecture allows for quick software modifications as well. “The power of that is that we no longer have to make changes to Azyxxi when there’s a change to the source system,” Smith says.

An advantage of this strategy is the single, customizable view of a patient’s condition and related pertinent information — and simplicity for the end user. “If it requires training, it’s too complicated,” Smith says.

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