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Best of Breed for Clinical Systems?

May 12, 2011
by Margret A., Mike Cohen, Jean Joslyn
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IT Approach solidifying its presence in acute care, also inching its way into ambulatory care

Once the domain almost exclusively of hospitals, it now appears that the best of breed approach to IT may not only be solidifying its presence in acute care but inching its way into ambulatory care as well. Many hospitals are trying to move away from such a strategy because it is costly to maintain disparate systems and the degree of interoperability needed to make such an approach succeed is very difficult to achieve. As more clinicians use health information technology (HIT), they want a seamless “look and feel” to the applications they use and for all data to be accessible without effort. So why does it seem there are as many new vendors introduced into the mix as there are efforts to consolidate on vendors?

• One vendor alone may not have all the desired modules, certain functionality may be believed inadequate in a primary vendor’s offering or may not be present upon “meaningful use” certification, new service lines are added by the care delivery organization (CDOs) that are not addressed by their primary vendor, or a favored product may be necessary to acquire for recruitment purposes.

• Striking differences in specialty requirements often mean the only way to automate the specialty information is through an alternative system. Consider the case of behavioral health (BH). Acute care hospitals with outpatient or community based BH services will find most acute care vendor solutions unable to support the complex billing and credentialing requirements of BH, and its stringent privacy requirements. In many situations, payers and institutions credential the caregivers. Documentation in BH thus requires the ability to link to scheduling and a matrix of credentialed individuals, as well as many other internal and external resources. For example, if a BH client has an eating disorder, intake staff must match the client to a caregiver credentialed by the client’s insurance for treating eating disorders, as well as such preferences as a female therapist under 45 who speaks Spanish. Ambulatory BH care billing is also much more complex, with a client potentially enrolled in four different programs, each with a different primary payor (e.g., grant, county, state). As the result of these and many other differences, hospitals with large outpatient BH services may have to use a product from a BH vendor, and then decide the extent to which an interface is necessary. And, BH is not the only specialty that poses such issues. A hospital may have a long-term care facility associated with it, or a primary care physician practice may acquire an occupational medicine practice with vastly different needs for billing companies rather than individuals.

• Niche products, such as clinical decision support engines, risk management systems, data warehouses for quality reporting, and patient interviewing tools are outside of the mainstream hospital information system (HIS) or clinic electronic health record (EHR) vendor offerings. However, there is increasing interest in integrating these directly into HIT solutions. For example, patients are frequently given medical history forms to complete prior to a clinic visit, yet the patient is asked the same questions during the interview with the physician. Several vendors have automated these forms, but unless they can be directly integrated into an EHR they are not much different than the paper form. More recently, vendors have created bubble sheets for scanning the information into the EHR or offer online tools that include branching logic to capture focused information and services to convert lay language to medical terminology and/or provide foreign language translation.This has significantly reduced the data entry burden for providers and is being recognized as a way to empower patients.

In summary, it is hoped that as the surge in adopting clinical information systems for the federal stimulus incentives occurs that CDOs focus on adopting integrated products and that vendors with functional limitations, specialty products, or niche applications work to improve and integrate their offerings. There is a growing body of evidence that “partial EHRs” that are part electronic and part paper or a mix of not well integrated components contribute more risk to patient care than either a fully integrated EHR or even a paper record alone!