August, 1996
Enterprisewide solution for integrated delivery
By E. Andrew Mayo, Executive Vice President, MedPlus Inc.
As managed care continues to shape healthcare, organizations are realizing the key to containing costs and improving the quality of care lies within the collection and analysis of both financial and clinical patient information. This has forced executives of healthcare organizations to rethink how their information systems will collect, manage and deliver critical information in a timely and cost-efficient fashion.
"Document information management" involves more than simply archiving large volumes of data. The goal is to transform this data into useful information. Careful consideration must be given not to just how data is stored, but also to the underlying architecture of the system. This is needed to ensure all enterprise applications will fit seamlessly into the overall integrated delivery system (IDS), and to ensure information is secure, reliable, available and organized in a way that will be meaningful for later analysis.
In a recent survey, 83% of organizations said they already are or will be soon part of an IDS. Today, it is no longer enough to consider only hospital-wide IS integration. Physician group practices, payors, ambulatory care centers, diagnostic centers and all other participants of the enterprise must come into play. These new systems must be capable of automating all patient care functions in order to deliver the enterprisewide tracking and reporting necessary to make more informed decisions and effectively compete as a healthcare provider.
When planning for the implementation of an IDS, the following questions should be given careful consideration.
* How will existing information systems, interdepartmental tasks and outpatient facilities be integrated to support an enterprisewide view of patient information?
* What are the infrastructure requirements of the IDS needed to provide central control and visibility of information distributed across the enterprise?
* How will this data be transformed into meaningful information for management to make more informed financial and clinical decisions?
Enterprisewide data needs
Before delving into the technical requirements of the IDS, let's first identify the key users of data and their associated basic needs for collecting, storing and communicating information within the healthcare network.
Medical records To a large degree, healthcare organizations move patient information from one area to another by method of a paper chart. To quote Dr. William Tierney, senior investigator at the Regenstrief Institute for Health Care, "Forty percent of the cost of running a hospital involves storing, collecting and moving information, and we can't afford the luxury of doing that on paper anymore."
The medical records information management portion of the integrated network serves three critical functions. Medical records and the associated medical records information system (MRIS) must be the source for the "legal" medical record. The need for a record that meets legal, regulatory and administrative requirements increases with the introduction of advanced information systems.
Secondly, CPR and point-of-care systems are so highly transaction-intensive, to avoid degradation of performance the MRIS will serve as the long-term data repository/archive for these systems. Finally, the medical records department has its own set of productivity needs which can be achieved only through automation and workflow.
The following medical records application requirements should be part of the mandatory guidelines when establishing an enterprisewide patient record.
* Deficiency analysis
* On-line chart completion
* Digital signature
* Extensible workflow interface
* Support for both electronically generated and scanned documents
* High security for confidentiality and legal reporting
* Release of information
* Integration with physician practice medical records
Business office. Just as cost containment efforts are increasing, the demand for clinical information systems, in addition to the pressure and complexity of administrative tasks, are increasing. Healthcare organizations are forced to interact with more payors than ever before, and the number of payor/payment possibilities has increased dramatically.
The hospital business office and/or patient accounting department must have a fast, automated system to increase productivity. In order to cope with higher volumes and complexity, immediate access to accurate data at each step of the billing and collection process is essential. An enterprisewide system addressing the business office should consider the following as minimum requirements:
* Patient registration information
* Verification of benefits with payor
* UR notification
* EOB bursting and filing
* Write-off authorization
* Integrated medical/financial record
Physician office. In outpatient settings, the greatest advantage in providing an enterprisewide patient view of information is gaining the productivity and cost savings of sharing the current financial and clinical patient information between the hospital, physicians and other points of care. Managed care organizations are also putting extreme pressure on healthcare providers to deliver proof of low-cost and high-quality outcomes. These demands require physician practices to be able to demonstrate patient outcomes over time. Without the information systems in place to collect and analyze clinical information, this becomes an impossible task.
Integration of the physician office requires that the following be considered:
* Integration with physician office billing and financial systems
* Automated appointment scheduling, referral authorization and management reporting
* Integration and sharing of electronic patient medical information with hospital
* Security and integrity of data over public and private networks
* Physician satisfaction and buy-in of technology
* Sophisticated point-of-care data entry
Architecture for an enterprisewide patient record system
The migration to an enterprisewide patient record is a step-by-step process; one of the most important of which is creation of the foundation and infrastructure. When you build a house to last a lifetime, you need to start with a solid foundation. Likewise, when you are building an enterprisewide patient record, you will need a solid base to weather the many structural changes that will occur over the years in the evolving healthcare system.
The "foundation" of the enterprisewide patient record is the distributed data repository (DDR) which houses the clinical, financial and all other pertinent patient record data. The DDR serves as the "bank" from which all other information sources--medical record systems, physician office systems, clinical expert systems, decision support systems and financial and billing systems--draw. Because all patient record activity hinges on this vital element, it makes sense to first select a partner before purchasing other information systems.
There are several important issues to consider when selecting a DDR. The data repository must be compatible with any information system, reliable to ensure uninterrupted, foolproof operation during unanticipated periods of downtime; and secure to ensure patient confidentiality. It is also important to consider the nature of the information to be managed. Because approximately 60% of all hospital data still resides on paper and non-digital sources, it is essential to find a DDR that incorporates hard copy as well while meeting all legal and administrative requirements.
System compatibility and integration
The major consideration when selecting a DDR is the ability to interconnect the multiple institutions within the integrated delivery system, each with different information systems and requirements. Because information will most likely need to be stored and managed for decades, you must examine not only your current system needs, but future needs as well. Will the system you buy today be compatible with systems purchased by another IDS member tomorrow? Will it be compatible with systems added later by other facilities due to mergers or acquisitions? These questions must be answered before selecting a DDR provider.
By choosing a DDR with open, flexible hardware and software tools and interfaces, you can ensure it will be compatible with any information system, instrument or component. This provides the freedom to integrate existing applications and add new ones as required in the future without replacing your information system. This not only ensures enterprisewide integration, it protects your investment, an increasingly vital requirement as managed care, increased regulation and other factors further affect healthcare budgets.
The DDR provider should be able to offer an open systems strategy that includes:
* A wide choice of proven hardware
* Standards-based methods to get data into and out of its database
* Easy integration with other applications
* The ability to store all data in a non-proprietary format
A truly open system offers applications that follow widely accepted products and standards, such as:
* Oracle database: the most popular SQL database engine.
* TCP/IP: the communications standard that provides easy integration to other systems. TCP/IP is supported over all major network transports, including Ethernet, Token Ring, ISDN, and serial/dial-up interfaces.
* HL7 interfaces: for clinical data transfer. The system should also include an embedded interface engine to translate disparate interface messages before they are passed to the DDR.
* MS/Windows: the graphical user interface, familiar to most users, which enables multiple, coexisting applications on any PC.
* Unix and Windows NT servers: the most widely used and scaleable server operating systems for business applications.
* TIFF and standard Microsoft Rich Text Format (RTF): two industry-standard formats which enable image and text to be used by all major word processors and related applications.
* Kofax API scanning interface: proven for both high- and low-volume, mission-critical scanning, it supports all major scanner manufacturers.
* AMASS optical management software: an interface which is supported by various optical providers such as HP, Sony and Hitachi.
* Workflow engine: a system that automates and manages the various functions within the IDS by collecting, storing and communicating the vast amounts of information generated within an enterprisewide healthcare continuum.
System reliability
The DDR plays a vital role in both everyday and mission-critical functions of the IDS. Its central role necessitates a reliable and resilient system that is available 24 hours a day, seven days a week. As the size of databases goes beyond gigabytes to terabytes, information backup and recovery of information can become an increasingly time-consuming and overwhelming task. Downtime is not a luxury healthcare providers can afford in today's increasingly chaotic, competitive healthcare market. Expedient back-up and recovery of information is a must when seeking a DDR system.
To ensure information is completely recoverable, the DDR should contain an SQL database which can provide up-to-the-minute recovery of information in the event of unscheduled downtime. Only the most robust SQL database engines, such as Oracle 7, are designed to handle thesemission-critical applications. With Oracle, you can even back up your database while it is still active and in use by end-users (also known as "hot backup"), reducing or even eliminating scheduled downtime.
Security and confidentiality
Security and confidentiality is of utmost concern when establishing an enterprisewide computerized patient record. With its expanded user access and the emergence of sensitive information such as HIV tests, it is more important than ever to find a system with the sophisticated security to protect patients' privacy.
A DDR with an effective security component polices the system to ensure it cannot be easily circumvented. For instance, to prevent unauthorized users from using someone else's password, the DDR should never send passwords in text format over the network. Passwords should always be encrypted.
A DDR must possess these security features:
* User and group models: Users are assigned to one or more "user groups" that typically correspond to certain job functions. Permission to run applications or perform chart functions are assigned to groups and/or individuals.
* System access security: All users must enter a login name and a password prior to accessing any DDR application. To make it more difficult for unauthorized users to access the system, all users must work from an authorized workstation where client software is installed. An application lock allows a user who must leave a workstation to temporarily lock the application so no one else can enter it.
* Application security: After logging into the system, users are presented only with those applications (such as sign-off, chart completion, etc.) to which access has been granted.
* Chart security: This enables the person administrating the system to control which charts users can access and what operations they can perform (i.e., who can view charts of a care site, who can edit a document, who can print charts, etc.) It should even control which documents within the chart the user can access (i.e., AIDS results, etc.)
* Encrypted digitized signature: A signature password verifies the user's signature authority. The system encrypts the signature, along with stored signature attributes, to make it tamper-proof and legal.
Conclusion
With the growth of integrated delivery systems and expansion of managed care, one thing is clear: traditional paper methods of storing and managing information will no longer suffice. To achieve a competitive advantage, contain costs, improve quality of care and attain physician participation, information technology solutions are mandatory. Assembling an enterprisewide patient record requires many pieces which must all fit seamlessly together, possess a solid infrastructure, and be readily and easily accessible to all members of the IDS.
As healthcare becomes more complex and forces such as capitation become more prevalent, providers will be required to do more than store and use daily information; they will need to analyze trends and practices vital to their organizations. With proper planning, the right technology partners and cooperation from all IDS members, your organization can assemble an integrated solution that achieves
these goals and ensures your success in today's competitive marketplace.
E. Andrew Mayo is Executive VP of MedPlus Inc., a health information technology provider in Cincinnati. Contact MedPlus at 8805 Governor's Hill Drive, Cincinnati, OH 45249, 800-595-0218, E-mail, www.medplus.com.
Business management decision support for healthcare executives
Cost-conscious healthcare organizations are now realizing the key to controlling costs lies in their ability to leverage information technology to eliminate costs and streamline operational processes. This can be realized only if the mountains of information captured within the IDS is made available in a timely fashion and in a format that helps healthcare executives make more informed financial and management decisions.
Three big issues confront MIS managers when they areconsidering decision-support applications:
1. How will healthcare organizations allow access to up-to-date data without bringing mission-critical systems to their knees?
2. How can decision-support applications ask constantly varying questions about the same data without tying up an army of programmers to write queries and reports?
3. How can decision-making executives get their answers in seconds?
The data warehouse (an often misused term) is the foundation in supporting decision support systems. It serves as the central "nerve" where data from numerous systems is collected, stored and summarized into a "multidimensional" view of information. This multidimensional view gives healthcare executives the information they need in a view familiar to how they want to manage their organization.
For example, when analyzing physician practice patterns, a hospital administrator may wish to assess the level of efficiency of all group practices by looking at the number of patients seen for each physician, how much revenue was generated by each group practice, the number of tests and which types of tests were issued, plus revenue by insurance provider, by treatments, etc. Each of these "views" or ways of analyzing information is referred to as a "dimension," hence the name, "multidimensional" analysis.
The examples included here illustrate how executives can analyze critical information in a format that is meaningful to them.
Without information systems that capture data, such as patient demographics and physician practice patterns, controlling costs and providing a higher quality of care becomes extremely difficult.
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