August, 1996 Application integration: An essential ingredient By Howard L. Tischler, President SunGard Healthcare Information Systems, Intelus With the vast majority of the medical records still on paper, a significant opportunity exists to use document imaging and workflow management to improve efficiency, record access and ultimately patient care. But while imaging and workflow represent fundamental ingredients to the success of an electronic medical record system, they are merely a starting point. Being successful in the challenging world of medical record management requires more than advanced technology. The electronic medical record application offers a host of challenges not encountered in any other market or application including confidentiality issues, legal requirements, financial implications and a demanding set of unique healthcare applications. Add to that the intensive effort needed to deliver records for patient care and a wide range of different system users including physicians, it is clear that success requires much more than a simple repackaging of disparate systems. In addition to a true open system architecture, a successful imaging and workflow system also requires integrated application software, application enabled workflow, specialized document scanning and indexing, and healthcare-proven electronic data exchange software. Healthcare integration on all system levels is a prerequisite to success. Application integration There are several core healthcare applications and programs that are so interrelated with the medical record, that it is only logical to incorporate them into any electronic medical record system. Among these are health information management applications including chart completion, electronic signature, release of information, master patient index, transcription, chart request, and even hard-copy chart tracking. Additionally, there is a host of clinical data management applications that also merits tight integration. These include medical record abstracting, utilization review, quality assurance, infection control, tumor registry, risk management, medical staff credentialing and care path management. An electronic medical record system that includes these record-intensive applications as a part of its core product can deliver productivity, accuracy, and record accessibility not otherwise attainable. Take chart completion as an example. Physicians and other healthcare providers are required to complete records in a timely fashion or it can have significant impact on hospital accreditation and patient billing. When the chart completion process is fully integrated with the document management system, this process can be expedited. The presence or absence of particular documents in the electronic medical record can automatically trigger deficiency assignment in the chart completion system. If the electronic medical record system is not integrated with chart completion, an analyst must manually review each document to assign deficiencies. From the physicians' point of view, chart completion integration dramatically improves communications and convenience as well. Chart deficiency notices and related documents can be presented electronically on the physician's workstation and any on-line completion activity will automatically update the completion system. Integrated hard-copy chart tracking is also a required application for most facilities. This may seem like an odd requirement for an electronic medical record system but it serves two purposes. First, during the transition period from paper to the electronic record, bar-code-based chart tracking can be used to locate records that exist outside the electronic record system. Second, chart tracking is used on an ongoing basis to manage the distribution and location of record copies printed from the electronic system. Because of confidentiality and legal issues, tracking the location of record copies can be very important. Healthcare enabled workflow Optimizing workflow is an important consideration for an electronic medical record system. It is valuable that the system be able to route work and documents automatically, while tracking and managing workloads and work status. Workflow can dramatically improve communications and productivity, while providing a powerful business process reengineering tool. But, simply having an off-the-shelf workflow product is not enough. To be truly effective, workflow must be fully integrated with the system and its applications. Take clinical data management as an example. As part of the abstracting process, an integrated rules-based workflow product can automatically route a case to a different department, like Quality Assurance or Risk Management, based on the presence of a data value or the existence of a specific condition. Non-integrated workflow products operate outside of the application and cannot offer this type of productivity gains and system control. In addition to having workflow integrated with the application, the workflow product should also be fully integrated with the database as well. A good example of the benefit of this type of integration can be seen in workqueue management. Many sites set up coding workqueues based on the dollar value of the chart. The more valuable, the higher priority. If the finance system changes that dollar value for an episode, a database-integrated workflow product will automatically change the priority of the episode in the workqueue based on the revised chart value. With a non-integrated workflow product, manual routing of the episode is necessary to place the record in its proper place in the queue. Integrated workflow does not mean that the workflow engine be proprietary. Quite the contrary, it is vital that the workflow product adhere to the Workflow Application Programming Interface (WAPI) standards from The Workflow Management Coalition. WAPI defines the API set for building workflow-enabled applications. The support of these standards in workflow products permits front-end applications to access workflow services. Open workflow can greatly enhance the value of legacy healthcare applications. Media and workstation independent document management The electronic medical record system requirements stretch well beyond just document imaging. In addition to images, the system must efficiently capture, store and display documents and related data in a variety of forms including electronic text, transcriptions, computer output to laser disc (COLD), signal tracing, digital photography, diagnostic images, and, in the not to distant future, voice annotations and full-motion video. The first requirement is that your system must be media independent. The database must support object-oriented structures to accommodate the wide range of document and media types included in the medical record. Next, the system must be able to automatically launch the proper viewer based on the type of document to be viewed. For example, when a laboratory result received through COLD is to be displayed, the system should launch a blank Lab Report and map the results to the proper locations on the form (forms overlay). Or if a transcribed document like an operative report is needed, the system should automatically launch the proper text or word processing viewer. Finally, the record must be accessible when and where its needed. Since many healthcare institutions support multiple types of workstations, documents should be viewable on a wide range of different clients. The system should support a wide variety of different PC operating systems including Microsoft Windows 95, NT and 3.11, OS/2 PM, X-Windows and OSF Motif, as well as the physician's favorite: Macintosh. In addition, specialty devices like X-terminals are popular in many university hospitals. With the surging popularity of the Internet and Intranets, viewing of documents should also be extended to web browsers as well. Specialized document and data capture requirements Document scanning and indexing takes increased labor to accomplish. Generalized scanning and data capture products shortchange the electronic record application by not optimizing the capture process and can cause system bottlenecks. First of all, the system should be configured to meet the automated indexing needs of the facility. Using an integrated combination of bar code, optical character recognition (OCR) and forms recognition, the institution should be able to automatically index better than 90% of its scanned documents. This is only possible if the system addresses each institution's specific document types. Furthermore, a medical record system should go beyond traditional scanning and indexing in the name of efficiency and accuracy. One example is in the input of hand-written clinic notes. An integrated system can print a blank clinic note at the time of the appointment and then automatically link the completed document to the patient and episode of care when the form is subsequently scanned into the system. Since up to 60% of the medical record can be captured directly from other applications, there is a critical need to receive and exchange data with a number of other systems. This direct data exchange can dramatically reduce scanning and indexing requirements, computer storage costs and network load. Among the systems to which data exchange may be required are admission/discharge/transfer, patient appointment scheduling, operating room scheduling, dictation, transcription, coding, laboratory, pathology, pharmacy and finance. It is imperative that the electronic medical record system be equipped with Health Level 7 (HL7) interface software to facilitate data exchange with the institution's systems or an interface engine. In addition, some legacy systems cannot support HL7, therefore your electronic medical record system must also be able to accept free form electronic documents. Effective record retrieval For an electronic medical record to succeed, the institution's physicians must accept the system and participate in its use. Rule number one--retrieve records fast. Don't make physicians wait. Many systems migrate documents to optical storage in such a way that a single patient's record can be scattered on multiple platters throughout the jukebox. A system that is truly healthcare integrated will migrate the documents to optical storage in such a way that all episodes of care for a single patient reside on a single optical platter. This speeds retrieval of a patient's record by mounting a single platter to satisfy a record request. Without this type of integration, imagine a musical jukebox having to mount multiple records to play a single song. HL7 interfacing is key to efficient data capture, but it also plays an important role in document retrieval. Interfaces to an institution's patient appointment scheduling system can help efficiently stage records from long-term optical disc storage to faster magnetic disks. Using specialized algorithms, the system should automatically cache records for patient's with next day appointments to magnetic disk during non-peak hours. That way, the record is available instantly for all appointments, while reducing the system and network load during peak system use. This helps maximize system efficiency for all STAT requests. Healthcare-aware At first glance it may appear that general purpose imaging and workflow is the answer. However, the real payback results from imaging and workflow that is integrated (versus interfaced) with your healthcare applications. Integrated access to documents means the patient record automatically appears at the appropriate times in the application. Embedded workflow means work automatically appears in the appropriate users workqueues, in the correct order, without manual intervention. Workstation independence means the patient's record is available anywhere within the healthcare network --whether it be an IBM-compatible personal computer in medical records, a Macintosh in a physician's office, or a UNIX workstation in intensive care. Healthcare-aware document capture and retrieval means reduced cost and speedier record access. As a healthcare provider, do not settle for anything less than the best--an integrated solution. Howard Tischler is the President of SunGard Healthcare Information Systems, Intelus Division. SunGard is a leading provider of health information and clinical data management products. The fully-integrated SunGard 2000 product suite includes ChartFlo 2000 EMR, a multimedia electronic medical record system; ChartFlo 2000 SE, a bar-code-based medical record management system; AccountFlo 2000, an imaging and workflow system for patient accounts; ProcessFlo, a workflow management system; and SunGard Enterprise 2000, imaging and workflow systems for human resources, purchasing, accounts payable and other departmental applications. For more information, please call 800-990-6363. Fax: 301-990-6011.
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