Navigating the Maze
EHRs offer the potential for a major transformation in the way that health services are delivered and the value derived from them both in the U.S. and in other countries. By comparison, other recent initiatives such as administrative self-service Web portals, regional service consolidations and new medical devices and diagnostic tools are merely incremental improvements to the healthcare system.
The Vision
EHRs provide a pathway for healthcare delivery systems to achieve goals that were previously unattainable: Improvements that could be achieved through the close integration of information technology that is available with EHRs: ensure that the highest quality of care is delivered to every patient, ensure patient safety and prevent medication errors, identify the best treatment for each individuals specific situation, streamline administrative processes, reduce paperwork and redundancy, avoid duplicative testing, enhance access to services, yet closer tying of provider payment to performance and predicted clinical outcomes.
The possible rewards are great. But EHRs are much more complex than any previous IT initiative in health or, for that matter, in any other industry. In order to realize their benefits, health executives must develop EHRs in an integrated manner. They must implement EHRs so that they address several different dimensions:
Setting of care. EHRs have potential applications in almost every care setting including: preventive, acute, post-acute, subacute chronic, long-term care, community and home care. To be fully effective, EHRs need to be integrated across the entire continuum of care.
Geography. Health leaders need to design EHRs based on local needs and practice patterns, yet integrate the information that they contain and functionality they provide across the entire country including regions, states, provinces and local cities or jurisdictions.
Patient health information. Clinical information itself contained in EHRs is a dimension of challenge to EHRs on its own. While standards exist for this information, they are not widely used, and even when used are applied inconsistently within organizations today.
Clinical specialty. Clinical information and functional needs that support specialty-specific clinical processes exist in many areas such as emergency care, laboratory, radiology, pharmacy, intensive care and medical and surgical services.
Industry sector. Diverse stakeholders in the health industry need to share and coordinate clinical information. They include: hospitals, physicians and other clinicians, payers, community and social service organizations, government/public health, and even life science companies.
Function. Clinical information must be integrated across supply chain, financial and clinical systems to better understand and control the care delivered, ensure availability of material resources both when and where needed and to monitor revenues versus costs.
Resource. Full implementation and deployment of EHRs must consider integration from people, process, technology, facilities and financial perspectives.
The Need for Integration
At the same time this country is gearing up to pursue portable EHRs for every individual, most entities are already in the process of pursuing initiatives that involve clinical information systems. These existing initiatives have already created a local maze of agendas for change. All of these involve some level of significant investments in technology. This current investment underscores the ongoing role that technology already has and the even greater need for integration of information across clinical and administrative processes that will exist in the future.
Integration here covers many different agendas, and there are a number of potential integration points that health executives need to consider in their business and technical strategic plans. As always, technical integration must be an enabler to the definition of integrated operational processes and performance management.
As an example, consider pay-for-performance programs. Congress, CMS and many private payers have already pushed forward in their planning, which can have a profound impact in redesigning provider incentives for care delivery and are being considered by many countries around the world. The implications on provider behavior, care delivery, operations and financial performance are significant; the implications for technology integration are equally significant. The clinical information systems used to document and code the provision of care across the delivery system (acute, mental health, community nurse, etc.) and report the clinical outcomes will need to be significantly upgraded to collect more detailed and relevant data and then integrated with the local financial systems as well as the EHR. Accurate reimbursement for services will need to become tightly aligned with the accuracy of the clinical reporting.
Strategies for integration in the past have been comparatively narrow in focus with a very limited amount of abstracted data. New HIPAA transaction requirements and statutory requirements of the recently passed Medicare Modernization act have already put forces in motion that will ultimately require the providers to collect, integrate and then communicate far more detailed information if they expect to participate and not be left behind.
The Current Maze
At present most electronic record systems do not integrate with those of other vendors (and some systems offered by the same vendor arent even integrated with each other). Most vendors currently offer their products on a variety of hardware and associated software platforms. Each vendor has chosen a particular approach, and no two vendors have even a similar approach, much less a detailed design. No two site implementations of any vendors systems are the same. No two sets of interfaces are the same, and no two implementations use the same vocabularies or coding systems. In short, nothing is designed or implemented to interoperate beyond a specific implementation at a single organization or facility.
Currently vendors design their applications with a baseline assumption that their approach and architecture doesnt need to coexist and interoperate to be successful. They often support integration with external applications (i.e., those outside of those that they build) with significant differences in philosophy and detail. Moreover features that work across a vendors own integrated applications will not always cross over foreign system interfaces in exactly the same way. And even if a hospital would like to implement a total vendor solution, it may not be practical on many different dimensions of time, scope, economics or provider organization politics.
True interoperability will require that all features and functions work across all applications. The term semantic interoperability is now being used to describe a level of integration that facilitates the movement of data and process context between systems. A practical definition of semantic interoperability is the interchange of data where not only can the information be transmitted among systems, but the receiving system can understand the data and process contexts that it was created in and reuse the information in many different contexts, across all healthcare information application domains. This includes documents, reports and rules for decision support.
There is a high probability that any vendor chosen today will have to significantly alter their approach to internal and external integration, security and nomenclatures over the next few years. Many governments have already started to particular standards for integration and nomenclature to support portable electronic medical records. Providers will be motivated to comply. Payers and political voting influence forces are beginning to demand it.
Opportunities for Integration
When one considers the changes the programs will make in the daily operations of the care-providing organizations, the number of integration points and possibilities for further improvement begin to take shape. Some initial examples include:
- How can patient data from EHRs be used to both collect the data necessary to support identification and proactive care for patients at high risk of long-term chronic conditions and then ensure their subsequent treatment follows current best practices?
- How can EHRs be used to support and coordinate pay-for-performance programs both for the EHRs themselves and for other programs such as electronic prescribing that will both require data stored in an EHR and also interact with EHRs?
- As new EHR systems are deployed, how will we make sure that the new technology does not burden and create more work for providers but rather create incentives to change processes and enhance provider work flow?
- How can EHR systems support evidence-based medicine? How can they be used to manage outcomes?
For the above and other integration points, what service level and operational principles must be adopted among stakeholders and organizations to ensure success of the whole system? How will behaviors and reactions of clinicians and operational staff be positively directed throughout the transformation? How will the roles and performance management systems change?
What Next? Key Tenets of Any Integration Approach
While approaches will vary based on the stakeholders involved and the strength of their relationships, as well as the condition of their current situation, we envisage five key tenets of any integration approach.
- View the entire health delivery chain. The value of integration becomes clearer with an understanding of the delivery chain for care provision across diverse organizations (government, private, local community, social care, volunteer, pharmaceutical companies, etc.). Critical aspects of the delivery chain to be understood include: Each stakeholder in the chain has a different incentive for participation and each has a differing impact on the patients care experience; information requirements vary by stakeholder and the flow of that information to each stakeholder is different in form, timing method for delivery and legal privacy restrictions; each stakeholders compensation models and the implications on incenting the proper behaviors across the value chain differs; and timing, political and contractual realities influencing and enabling integration for each stakeholder.
- Value the integration as part of the justifying business case. Stakeholders need to acknowledge that the greatest benefits of EHR systems are not derived from technology implementation alone. Rather, integration can produce tremendous benefits in terms of patient outcomes, financial performance, better ways of working and employee job satisfaction.
- Secure stakeholder commitment and ownership. Sponsorship by top leadership from each stakeholder is critical. In all cases, the buy-in of the clinical community is essential to adoption and the success of any healthcare venture including integration of services, processes, data and technology.
- Apply resources to define, manage and control the integration. Hallmarks of successful implementations include physician and nursing leaders that bring universal provider adoption, strong solution architects who control the definition of the solution as well as leadership from a management team that keeps close tabs on critical path milestones and ensures rapid resolution of issues. Project management resources need to be invested in integration.
- Look beyond the technology. To be effective, systems implementations at any level need to consider more than the technology changes required. Health executives need to address people and process changes as well. Only by integrating the necessary changes in associated business processes and roles can technology achieve its full potential.
Conclusion
The U.S. government continues to press ahead with its plans for portable EHRs for every individual in this country. This is an extremely complex undertaking and will prove to be an expensive one. A portable EHR, however, is one more element of how both government and the private sector are focusing on reforms to healthcare delivery. Healthcare executives need to develop their strategies, plans and budgets with a goal of integrating their efforts for EHRs with other initiatives that will, in most cases, involve some of the same information and many of the same stakeholders.
True change occurs when process and information flow consistently and efficiently across the system of care. Through integration, EHRs will offer us yet another new opportunity to add value to the consumers and providers of healthcare.
