Perspective Ramez Shehadi Dr. Walid Tohme Jad Bitar Fit for Purpose Developing Enterprise- Wide Electronic Medical Records
Contact Information Beirut Ramez Shehadi Partner +961-1-985-655 ramez.shehadi@booz.com Dr. Walid Tohme Principal +961-1-985-655 walid.tohme@booz.com Jad Bitar Senior Associate +961-1-985-655 jad.bitar@booz.com
EXECUTIVE SUMMARY As healthcare providers transform their business models to focus on delivering a continuum of care for their patients, they are under increasing pressure to ensure that critical information is available in the right place and at the right time. Although traditional hospital information systems worked well in a world in which patients needs could be met within a single facility, that technology is evolving to connect the growing network of facilities and caregivers that are engaged in serving a multitude of interconnected patient needs. These constellations of facilities and providers are increasingly supported by a large set of healthcare technology systems all of which rely on electronic medical records (EMRs). By creating a holistic view of patientrelated information, EMRs bring the promise of enhanced quality of care, reduced medical errors and costs, and improved business performance for healthcare organizations. Today, a range of enterprise EMRs is available to help bridge existing information gaps, make healthcare institutions operate more efficiently, and improve patient satisfaction and outcomes. Knowing which technology fits best for each organization requires a careful analysis of which core functions a facility needs, what requirements it has for clinical information systems, how the capabilities of existing facilities can be leveraged and integrated into the network, and what constraints may be involved in executing an enterprise EMR solution. In the absence of this tailoring, organizations may end up with an EMR solution that doesn t fit their own particular needs and the quality, cost savings, and performance that EMRs promise would be wasted. 1
KEY HIGHLIGHTS A combination of competitive pressures, patients demands, technological advances, and expanded rules and regulations is forcing healthcare organizations to migrate from stand-alone facilities to integrated, full-service provider networks. Traditional technology solutions that helped stand-alone facilities increase productivity and patient satisfaction are evolving in order to deliver an enterprise-wide view of patient care that incorporates multiple facilities and caregivers. Enterprise EMR solutions are credited with enhancing provider awareness of the full patient history, reducing administrative costs, limiting errors and data duplication, and contributing to increased patient satisfaction. When properly designed and tailored to the specific needs of each facility in the network, these enterprise solutions can bring the promise of enhanced care, reduced costs, and improved business performance. THE FORCES OF CHANGE One of the major changes affecting the healthcare industry over the past decade has been the transformation of its delivery model. Care outcomes are becoming an important indicator of quality within the healthcare community, eclipsing volume of patients, length of stay, and occupancy rates. And because today there are a greater number of co- morbidities and a higher prevalence of chronic diseases, patients more frequently need to be treated by different specialists over a longer period of time. Standalone facilities, with their increasing complexity and the additional time they require for reporting, are also struggling to comply with new regulatory demands. Regulations and standards, such as the Health Insurance Portability and Accountability Act (HIPAA), have been expanded over the last decade in order to cover different aspects of healthcare delivery, such as access to care, outcome of services, and confidentiality of patient information. Prompted by these pressures, providers have moved from a discrete view of care, in which they focus on specific episodes, to an integrated approach in which they aim to deliver a continuum of care to their patients from the cradle to the grave. This new delivery model is transforming the industry by replacing single providers with multiple- facility systems operating in integrated healthcare networks (IHNs) collections of various types of healthcare delivery facilities that include primary, secondary, and tertiary care (see Exhibit 1). These networks help facilities achieve economies of scale by pooling their buying power, eliminating duplicative administrative and clinical roles, consolidating technology applications and other equipment across facilities, and centralizing core business functions such as human capital and finance. Through IHNs, facilities attract a critical mass of cases, further developing their clinical expertise. From a care perspective, IHNs offer a more holistic view of the patient than was previously possible, along with better coordination across the different levels of care. This transformation of the delivery model from stand-alone facilities 2
to integrated healthcare networks demands technology solutions that link caregivers across an IHN, as well as outside of it. Such solutions give caregivers the access to patient data that permits them to effectively collaborate and to make the right decisions about patients care. Giving providers access to all patient data in one place across multiple facilities allows them to monitor and treat patients across the continuum of care, and better leverage evidence-based medicine to increase the chances of successful treatments in similar cases. These technology solutions are also helping hospitals create a competitive advantage in the marketplace by making it easier for community physicians to interact with hospitals: With advances in medicine translating into shorter hospital stays and more outpatient treatment, hospitals are increasingly looking to physicians to refer patients. Exhibit 1 Different Levels of Technological Needs for Organizations in a Sample IHN General Hospitals Specialty Centers (Imaging Centers, Reference Laboratories, Outpatient Clinics) Primary Care Clinics Note: The size of the object representing each organization illustrates the degree of functionality required of that organization s EMR solution. Source: Dr. Mohammad Al-Yemeni presentation at HIMSS IT Leadership Summit, Oman, November 2009; analysis 3
EVOLVING TO AN ENTERPRISE VIEW This growing constellation of facilities and providers is supported by a large set of healthcare technology systems that rely on EMRs. Essentially, the EMR is a single record that provides a patient s information across facilities, and encounters. By using a unique patient identifier, an EMR is able to capture all of a patient s data, such as age and sex, personal characteristics, laboratory and radiology results, and current medication and allergies. This record becomes the sole source of information for a patient and can be accessed by physicians, nurses, referring doctors, and other authorized users either within medical facilities or remotely through a secure connection. It is the centerpiece and the unifying factor within an IHN s integrated application portfolio. The emergence of IHNs in healthcare delivery is changing the EMR landscape, as hospitals now interact with a number of facilities and other outside partners. As a result, the standalone EMR needs to be replaced with solutions that can support a provider s different network facilities by linking modules to EMRs for additional functionality. Basic EMR solutions cover functions such as clinical documentation and capture, clinical dashboard, clinical workflow support, controlled medical vocabulary, and a clinical data repository. EMR solutions allow hospitals to better manage their patients and their facilities through one system, improving patient care and increasing productivity and patient satisfaction. To gain efficiencies throughout the hospital, basic EMR solutions interface with other clinical and administrative systems such as hospital information systems (HIS), pharmacy information systems (PIS), or lab information systems (LIS). An enterprise EMR goes a step beyond the basic EMR solution by comprising a set of clinical functions and workflows that are fully integrated to provide patient information throughout the continuum of care (see Exhibit 2). Exhibit 2 EMR Solutions Offer Varying Degrees of Functionality Based on Organizations Needs BASIC ENTERPRISE EMR FULL ENTERPRISE EMR Scheduling Clinical Decision Support Interdisciplinary Care Plan Scheduling Pharmacy Information Admission, Discharge & Transfer Registration Single Patient Record Referral Tracking Nurse Triage Admission, Discharge & Transfer Registration Single Patient Record Referral Tracking Patient Billing Enterprise Master Patient Index Medical Administration Record Enterprise Master Patient Index Clinical Documentation Computerized Physician Order Entry Note: There are also interim options between the basic EMR solution and the full EMR solution, which can be customized for individual facilities needs. Source: 4
Although solutions vary from vendor to vendor, an enterprise EMR typically integrates the core functionality of a stand-alone EMR (i.e., a single patient record) with various additional modules, including: Enterprise master patient index (EMPI): This module ensures that the patient database is normalized by eliminating duplicate records and by preventing users from creating them inadvertently. Typically this module will cross and match data elements from patient demographics, registration data, and encounter data from all clinical and administrative systems. Computerized physician order entry (CPOE): This system enables caregivers to order laboratory and radiology tests, evaluate patient status, and document the actions they have taken. Clinical decision support system (CDSS): The CDSS helps caregivers make more- informed decisions based on all possible information through a rules-based engine. For example, a CDSS will assist caregivers by checking for drug interactions, incompatibilities among prescribed drugs, and a patient s allergy profile and dosage errors. The clinical and administrative benefits of an enterprise EMR are widely recognized within the healthcare community: Improved outcomes, because caregivers have access to a patient s full medical history Improved service, as the automation of many low-valueadded tasks allows caregivers to focus more on patient care Fewer errors, thanks to standardization across departments, analytics, and smart systems Reduced administrative costs due to increased productivity, decreased duplication, and the elimination of manual entry, as well as a reduction in multiple requests for similar diagnostics Increased patient satisfaction due to improved service delivery time and increased caregiver focus on patients To achieve all of these benefits, an enterprise EMR must be able to fully integrate with other existing clinical and administrative systems within the IHN. Often, systems exhibit the ability to communicate with one another through the exchange of data such as patient demographics, but they are not capable of exchanging critical decision support data, including alerts. This failure arises from the lack of integration between multiple solutions and providers, and points to the absence of clear interoperability standards. An enterprise solution from a vendor, which is typically integrated, can solve these interoperability issues. To achieve the full benefits of an enterprise EMR, it must be able to fully integrate with other existing clinical and administrative systems within the IHN. 5
ONE SIZE DOES NOT FIT ALL Primary, secondary, and tertiary facilities typically have different needs in terms of their EMRs. As such, these facilities place a high value on the ability to customize enterprise EMR solutions to fit their individual needs. For example, one facility may need a slimmeddown EMR system with minimal scheduling capabilities, while another will require a full-fledged EMR system with the ability to control bed usage. Vendors today are increasingly offering solutions with more powerful hardware and more customizable software that are more responsive to healthcare providers needs. Partnerships and acquisitions have helped a few vendors to offer enterprise EMR solutions that serve many users referral management for community doctors, CPOE and EMR for caregivers, and revenue cycle management for administrators tightly integrated in a single enterprise system. The key is to understand each provider s needs. During s recent development and implementation of an IHN IT strategy, we analyzed the enterprise EMR requirements of nine facilities within the IHN (see Case Study: Tailoring an Enterprise EMR ). The facilities ranged from large multi-specialty hospitals to midsized specialty centers to small primary care centers. Our review of specific facility requirements revealed that a basic EMR was not sufficient for all facilities, but a full enterprise EMR was excessive for some facilities and would be too costly and complex to deploy and manage. To customize the EMR solution, we went beyond the two-level basic and enterprise models and categorized the IHN facilities into three groups according to their EMR requirements: basic enterprise EMR, partial enterprise EMR, and enterprise EMR. Basic Enterprise EMR The basic EMR solution is best suited to small physician offices (around 10 doctors) that need a quick, affordable solution which integrates the single patient record with a few additional modules. Some vendors claim to be able to install such solutions very rapidly (one practice per week), including go-live support. In a recent study for a large IHN, we found that basic EMR vendors combined elements of the common hospital database, such as insurance information and patient data elements, with tailormade functionality that met the physicians specific demands (e.g., area pharmacies, ordering privileges). Typical modules within a basic EMR solution include an EMR/ single patient record system with minimal functionality, or a scaleddown version that includes just health information and data; registration and scheduling; limited prescription order entry; and laboratory and radiology results. Partial Enterprise EMR This version is often used by specialty center facilities that require more functionality than a small clinical office but have fewer and more specialized needs than a large, general multi-facility hospital because of their 6
CASE STUDY: TAILORING AN ENTERPRISE EMR A major healthcare investor was building an integrated healthcare network encompassing several facilities, including an acute care center with around 400 beds and a portfolio of outpatient clinics and specialty services, such as a diabetes clinic. The group wanted to understand how to create a centralized patient view by integrating clinical applications across these facilities, including EMR, radiology information systems (RIS), picture archiving and communications systems (PACS), LIS, CPOE, CDSS, and PIS. specialization (e.g., diabetes clinic or sports medicine center). Modules that appear in this category include all those in the basic EMR category, in addition to clinical decision support, electronic image viewing, and the ability to order laboratory and radiology tests. Typically such a solution for specialty centers requires significant effort to develop custom functionalities as bolt-ons to out-ofthe box modules. Full Enterprise EMR The full enterprise EMR is typically aimed at large, multi-specialty hospitals, but tailored to the facility based on clinical and administrative workflows. This version comprises the full suite of modules and functionalities available. In addition to the functionality offered by the partial enterprise EMR solution, additional modules that would be integrated include extended clinical documentation, PIS, nurse triage, patient billing, CPOE/order entry, medical administration record, CDSS, and EMPI. To define the most appropriate solution, we first identified key market trends in clinical information systems along with best practices in deploying them. After looking at top vendors offerings, caregivers needs, and the IHN s portfolio, we determined that EMR, HIS, PIS, CPOE, and CDSS should be offered as a single enterprise solution, with RIS, PACS, and LIS considered separately. We advised which capabilities should be offered centrally (e.g., order entry, image archive) at the enterprise level, and which should remain local (e.g., specific clinical systems). We then developed a target model for the IHN s EMR that took into consideration each facility s needs. For example, one of the facilities involved was a national reference laboratory focused on LIS that had no need for enterprise EMR functionality. One of the most challenging aspects of launching such a large enterprise system is ensuring interoperability across the different systems. To that effect, we designed an enterprise integration solution that makes sure all deployed systems can interface seamlessly. We also developed an operating model to ensure that the EMR is managed properly and that the different facilities needs are taken into consideration as the system evolves. The operating model included the team to manage the EMR once it was operational, the processes and policies to ensure its efficient operations (especially in capturing users needs), a budget that encompasses capital and operational expenditures to deploy and manage the EMR, and a governance model that aligns the EMR with each facility s objectives as well as with the IHN s overall objectives. Based on these recommendations, the team was able to articulate an integrated IT vision to the company s senior management that helped them achieve their vision of a paperless environment. The efficient exchange of clinical information across systems offers enhanced quality of care by providing clinicians with a holistic perspective on all their patients information and reducing the number of medical errors. The new system also lowers overall costs, including a significant reduction in administrative costs. 7
CONCLUSION By creating a holistic view of patientrelated information, EMRs promise enhanced quality of care and fewer medical errors, reduced costs, and improved business performance for healthcare organizations. However, delivering a multi-facility, multifunctional IT solution is a complex task and the typical onesize-fits-all approach typically offered by vendors is needlessly time-consuming and costly. A tailored approach that matches each healthcare organization s needs with the necessary EMR capabilities is essential. Before investing time and money in an enterprise EMR, healthcare organizations should undertake a thorough review of their day-to-day needs to determine which EMR solution fits the bill and what degree of customization is required. Without this tailoring, organizations may end up with an EMR solution that doesn t fit their own particular needs and the quality, cost, and performance promise that EMRs bring will be wasted. 8
Endnotes 1 For more information, please see Ramez Shehadi, Dr. Walid Tohme, and Jad Bitar, Healthy Links: Ensuring Interoperability in Healthcare Delivery,, 2009. About the Authors Ramez Shehadi is a partner with in Beirut. He leads the information technology practice in the Middle East. He specializes in e-business and technologyenabled transformation, helping both private corporations and government organizations leverage technology, achieve operational efficiencies, and improve governance. Jad Bitar is a senior associate with in Beirut and a leader in the information technology practice with a focus on healthcare. He specializes in healthcare and business technology, particularly strategy, organization, operations, and innovation. Dr. Walid Tohme is a principal with in Beirut and a leader in the information technology practice with a focus on healthcare. He specializes in the management and strategic use of technology to enable the transformation of healthcare organizations, services, and infrastructure. 9
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