Ambulatory Care
HIS vendors are racing toward the development and delivery of a CIS platform or
product that fully integrates inpatient and outpatient services, as well as physician
office practice settings, with common information systems that provide a shared
data repository, content, and common/integrated workflow pathways. This is the
biggest issue slowing vendor selection and impeding progress toward an integrated
future. Hospitals with the need to integrate their disparate inpatient and outpatient
platforms should select a system vendor that has the best potential for integration
and is willing to be held accountable for delivering future systems that can integrate
all clinical information and processes throughout the enterprise.
In today's clinical environment, inpatient and outpatient processes and functions most often reside in separate "silos," with little transfer of information from one departmental application to the other. In a hospital setting, though there's considerable crossover of patients from inpatient status to outpatient status and vice versa, there's little crossover of patient historical data or clinical information in either direction. Information from inpatient and outpatient clinical data repositories and clinical documentation systems, ancillary systems such as lab reports, placing treatment orders, and accessing results, needs to be laboriously and carefully fed (often by re-keying information or transferring paper documents) from one system to the other. The extent and seamlessness of current information-sharing capabilities often depends upon the model of the affiliation between the physician constituencies and the hospital. A hospital's ambulatory department may have significant ability to share information with other departments; however, if physicians are hospital employees or maintain offices on the hospital campus, information sharing is much more extensive than in community-based hospitals. In the current environment, data and workflow are disparate. In addition, physicians in separate ambulatory and inpatient "camps" have had tremendous incentive to invest in expensive tools for integrating and sharing information, but limited access to capital funding.
Moving from stand-alone systems to integrated systems presents many challenges. The highest standard of integrated patient care information would integrate physician offices and hospital patient information via common information systems, common data, and common workflows.
Best-of-Breed Applications or Integrated Solutions
The current CIS environment has been challenged to develop a fully integrated, feature-laden, and functionally rich tool that provides both inpatient and outpatient solutions. Today, many system vendors offer stand-alone information systems and applications to radiology clinics, wellness centers, ambulatory surgery, and other outpatient organizations. These best-of-breed solutions can be quite sophisticated and flexible, and answer the information needs of many independent clinics. A considerably smaller group of vendors specialize in advanced clinical information systems for inpatient organizations. Vendors traditionally have focused their development efforts either toward the inpatient or the outpatient segments. The trouble is, no vendor currently has available in full production a clinical information system that cleanly integrates both inpatient and outpatient workflow pathways, content, and data sets on a common platform. In a health care system that seeks to integrate inpatient and outpatient information and applications, decision makers face a Hobson's choice of a clinical system vendor offering best-of-breed solutions, or choosing a vendor offering solutions that may be less functionally rich, but are committed to enterprise-wide integration. As hospitals plan clinical transformation initiatives and begin searching for the right solution, the lack of inpatient/outpatient integration is a significant issue slowing vendor selection and impeding progress toward an organization delivering an integrated solution.
The Future Won't Wait
This situation is changing, though not rapidly enough to meet market demand. System vendors are under increasing pressure from health care organizations to address the integration of inpatient and outpatient clinical applications. Often, health care organizations begin evaluating inpatient systems and, under pressure from the physicians, try to incorporate outpatient solutions from the same vendor. System vendors are starting to respond to their customers' demands by redirecting their R&D efforts toward a fully integrated solution. Though most R&D dollars are spent expanding the features and functionality of an existing inpatient or outpatient solution, vendors of inpatient-focused clinical systems — under pressure from buyers — are working toward integrating outpatient information and applications with their existing inpatient solutions. Vendors of outpatient-focused clinical systems are approaching from the other direction, working to integrate their outpatient solutions with inpatient systems. It may be years before these efforts achieve fully functional integration between inpatient and outpatient systems. In today's economic environment of slow business growth and tight capital, funding R&D efforts to help pick up the pace of development isn't the system vendor's first priority.
Whom Do You Trust?
Clearly, as other sections of this book discuss often and at length, there is a sense of urgency driving a hospital's clinical transformation initiative. Hospitals or health care systems with both inpatient and outpatient services can't afford to wait for the perfect inpatient/outpatient integrated solution. So, the clinical system buyer must strategically pick the right partner, based on which vendor the buyer believes will reach the market first with the best product. Buyers must know exactly what they are buying and in what strategic direction the system vendor is heading. The buyer needs to develop a future strategy based on to-be-developed capabilities. Since a CIS implementation is a multi-year project in itself, a clinical system buyer must trust that the system vendor will deliver, by the time the system goes on line, the capabilities promised years earlier. This violates the "what you see is what you get" rule, so a strong, intensively collaborative relationship needs to be established among the buyer, the system vendor, and an experienced systems consultant. The systems, or clinical transformation consultant, can help to devise an implementation plan for an enterprise-wide clinical information system that integrates information, processes, and workflows in both inpatient and outpatient areas. The consultant can help negotiate with the systems vendor to provide a system that delivers the desired future state. The consultant also manages the partnering arrangement, and holds partners accountable for delivering promised resources and capabilities.
Sharing the Risk
A useful strategy for the clinical system buyer is to negotiate with the system vendor to share the risk. The buyer is basing vendor selection partly on promised or to-be-developed capabilities, potentially a risky proposition. It may make sense for the vendor to share the risk. A portion of the vendor's fees could be tied to meeting project timelines or delivery of promised capabilities. Putting a portion of fees at risk helps to hold the vendor accountable for delivering promised products or capabilities.
Impediments to Inpatient/Outpatient Integration
Privacy, a concern when patient medical information leaves the confines or control of the hospital, is seldom a consideration in an inpatient setting, but potentially problematic in an outpatient environment. Outside physicians, often distant from the hospital and loosely attached by medical privileges, cannot be given unfettered access to patient information. The hospital has the responsibility to verify and protect the patient information stored within its many applications and databases. Meeting the regulatory requirements established by HIPAA and others for sharing medical information about a patient is likely to add to the cost and complexity of fully integrated systems.
Planning for an Integrated Future
Health care providers know that the power of clinical transformation lies in integrating information, processes, and workflows throughout the organization. They are planning for an integrated future. Delivering this future vision of seamless, transparent, and automated sharing of information between inpatient and outpatient areas is one of the most difficult challenges of clinical transformation. We won't know precisely how difficult a task it is until someone accomplishes it. That's still in the future.
