This is the second in a six-part series that highlights the accomplishments of industry leaders in implementing electronic health records. Part 1 focused on academic medical centers, with other major types of provider organizations to follow.
The idea of the "health system" - an organization offering the full array of services needed by the local population - is a noble one. After all, by consolidating resources, these multi-hospital, multi-clinic organizations may run more efficiently and help patients avoid the frustrating experience of receiving their care in a fragmented setting. In practice, however, the business of assembling an integrated delivery system is extremely difficult.
For many systems, the electronic health record has become the linchpin of the entire organization. That's because the EHR is the common bond that enables caregivers to share information across clinics that are widely dispersed. A handful of leaders are making the vision of a "single patient, single record" come to life.
But there's way more to the challenge than implementing an enterprise EHR. Standardized workflows, standardized order sets and standardized treatment protocols are part of the mix as well. Following are snapshots of a handful of health systems that have tackled these challenges, embracing what may be the industry's toughest challenge.
Coping with Interoperability in a Best-of-Breed Environment
Organization: University of Pittsburgh Medical Center
Size: 20 hospitals, 3 million annual ambulatory visits, 175,000 annual inpatient discharges.
Staff: 2,500 employed physicians plus 2,500 affiliated physicians
Number of Applications: 200 clinical, 1,200 total
EHR Achievement: Two hospitals designated "Stage 6" by HIMSS Analytics
What's Next: Expand use of "closed loop" medication administration, other systems.
By any measure, UPMC is big. Encompassing 20 hospitals, UPMC typifies the modern health care delivery organization with both academic medical centers and community hospitals among the mix. On the EHR front, UPMC has invested heavily, spending more than $1 billion in I.T. over the past five years. The board-mandated deployment challenge has been enormous, with clinicians playing leading roles both as systems champions and hands-on analysts. Among UPMC's 1,400 I.T. staff, approximately 300 have clinical backgrounds, notes Dan Drawbaugh, CIO.
Like Trinity (see page 48), UPMC is attempting to standardize its technology. It has settled on two core vendors - Cerner and Epic - to handle its inpatient and ambulatory sides of the business, respectively. But beyond that, UPMC has turned to a multitude of software suppliers as it attempts to automate the highly specialized nooks and crannies in the operation. Nearly 200 niche vendors figure in specialty areas where neither primary vendor "has a viable product or functionality," observes Drawbaugh. For example, the mix includes a lab system from Tucson-based Sunquest Information Systems and a PACS from Philips Healthcare, Andover, Mass.
UPMC's efforts to capitalize on these systems have not gone unrecognized. It is among a handful of health systems that can count among its members a "Stage 6" hospital - a high-ranking measure of EHR progress defined by Chicago-based HIMSS Analytics, a market research and consulting unit of the Healthcare Information and Management Systems Society. In fact, UPMC has two such hospitals - Presbyterian and Children's - that have attained the HIMSS ranking, the cornerstone of which is "closed loop" medication administration. Now, the two hospitals can track all medications electronically from the point of order to the eventual administration at bedside.
By the end of 2009, many additional UPMC hospitals will have earned the stage 6 designation, predicts Vivek Reddy, MD, medical director, information technology. The key to advancing any hospital along the automation continuum, Reddy says, is detailed workflow analysis prior to, during and after go-live. The task is enormous. "We began the analysis at Presbyterian in 2005 and completed it in the spring of 2008," Reddy recalls. "Despite all that legwork, we wound up with many iterations of ideal workflows. Many of the things we mapped out in 2005 we had to revisit when we deployed."
Clinician involvement was instrumental in the process, adds Marianne McConnell, R.N. She serves as director, clinical/operational informatics at UPMC Presbyterian. "We rolled out the technology by stages across services lines," she recalls. "We got the buy-in from senior leadership for which went first, second and so forth."
Because Presbyterian is a teaching hospital, the staged roll-out made more sense than a big-bang, she says. "An academic medical center is a complex place - you have attending physicians, residents and house staff. All these people have to understand what is happening and be prepared for the change."
Often that required reconfiguring workflows, Reddy says. For example, when it came time to implement electronic orders for respiratory therapy services, Presbyterian had to backtrack, taking a month to fine-tune the order entry screens and workflow protocol. Eventually, it built in automatic notification to therapists after a physician had placed an order. In the paper world, such consultations took place on an ad hoc basis. "We went with the rule that physicians were comfortable placing the order electronically, but that we had to automate the notification and consultation as much as possible to not burden them with an extra task," Reddy says.
The sheer number of applications running across UPMC requires highly defined carve-outs of system oversight responsibility, notes Drawbaugh, the CIO. The interoperability challenge has been significant, the UPMC executives attest. UPMC maintains some 650 interfaces across all applications, Drawbaugh says. But that is not enough. It is relying on a local company, dbMotion, to do much of the heavy lifting in connecting its clinical applications. UPMC has an ownership stake in the company as well. Drawbaugh describes the approach as "semantic interoperability," meaning the software will identify buckets of clinical data that are associated and enable users to see them through a common screen.
UPMC is creating a unified patient record across the inpatient settings. Currently, its hospitals are divided into geographic zones. While most are running Cerner applications on the inpatient side, hospitals can not view data from another system hospital outside its own zone, says Dan Martich, M.D., chief medical information officer. In contrast, physicians can access the same ambulatory record regardless of locale, he adds.
Bringing together data from the ambulatory and inpatient settings requires appreciation of what clinicians on both sides of the encounter need, Martich adds. Physicians need a core set of data that includes medications, problems, allergies and immunizations, he notes. As the ability to pull data from the Cerner and Epic sides of the operation grows, such "essential medical data" will be consolidated through dbMotion. "We won't bring together every blood pressure reading," he says. "It would be nice to know every EKG or every glucose reading, but what physicians need are the essential elements."
Physicians who want more detailed background can find it by accessing niche systems, tied together by an enterprise master person index. "We are not propeller heads into I.T.," Martich says. "We provide cutting edge medicine and we combine it with the best in class I.T. in ways that help our patients."
The above is an abridged version. The complete article is available on-line at Health Data Management.