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Building Bridges

September 29, 2010
by Mark Hagland
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Helping MDs Cross the Inpatient/Outpatient Divide

EXECUTIVE SUMMARY

Healthcare CIOs and CMIOs have been working diligently to optimize clinical IT access and navigability across the inpatient-outpatient divide for their physicians. Given a broad spectrum of computing environments, and a shifting clinical IT landscape, every organization is ending up charting its own path in this complex area.

With 12 wholly owned hospital facilities, more than 3,300 licensed beds, and more than 3,600 physicians with staff privileges, the leaders at the Arlington, Texas-based Texas Health Resources (THR) had better have some kind of strategy to help doctors navigate their clinical information systems. Fortunately, they do. “We have a connectivity strategy we've been pursuing for several years, and we continue to leverage that strategy,” reports Ed Marx, CIO of the vast system.

There are several layers to the Texas Health Resources strategy, he notes. At its core, the system runs the EMR solution from the Verona, Wis.-based Epic Health Systems; THR offers the Epic outpatient EMR to its salaried physician groups (along with the EMRs from the Horsham, Pa.-based NextGen Healthcare Information Systems and the Westborough, Mass.-based eClinicalWorks, as additional options); and it wraps its physician portal, called CareGate, which has been in place for more than a decade, around those inpatient and outpatient systems. CareGate is also the chief point of access to the health system's picture archiving and communications system (PACS), Fuji's Synapse, and its document management system from the Cincinnati-based Streamline Health.

In addition, CareGate provides for robust, secure online communications between THR and its physicians. And beyond all that, in the past year, Marx and his colleagues have developed something called CareGateLink, which provides access to physicians not formally affiliated with the health system, but who need to interact with its hospitals or physicians in some capacity. That program has already attracted 375 physicians, and is expected to grow considerably, as is the health system's fledgling health information exchange (HIE).

Ferdinand Velasco
Ferdinand Velasco

The point to all this, Marx says, is that “You have to have a multi-pronged approach, strategically and tactically. We didn't just do a portal, but also created an HIE; and we then created CareGateLink to go beyond even our affiliated physicians. And we're implementing solutions that make things easier for physicians; it's all about improving quality of care, and making providing quality of care easier, through easier computing for physicians and improved access to data.” Adds Ferdinand Velasco, M.D., THR's CMIO, “It is important to note the [spirit of] collaboration with our physicians. We didn't just ‘do’ the portal ‘to’ them; we did it with them. And we're continually looking to refine and enhance our tools, which are their tools,” Velasco says. Next steps include adding social media tools to CareGate next year.

IT IS IMPORTANT TO NOTE THE [SPIRIT OF] COLLABORATION WITH OUR PHYSICIANS. WE DIDN'T JUST ‘DO’ THE PORTAL ‘TO’ THEM; WE DID IT WITH THEM. AND WE'RE CONTINUALLY LOOKING TO REFINE AND ENHANCE OUR TOOLS, WHICH ARE THEIR TOOLS.-FERDINAND VELASCO

DIVERSE APPROACHES

Ed Marx
Ed Marx

Very few hospital-based organizations have reached the level of complexity and sophistication of Texas Health Resources in their creation of inpatient-outpatient navigation solutions for their end-user physicians; but most hospital organizations of any size have at least begun to address the issue, as the adoption of core clinical information systems advances nationwide.

At the core, CIOs and CMIOs face a welter of options in this area, with no simple “silver bullet” solutions. A small minority have implemented the same EMR for inpatient and outpatient, but even those organizations need to create outside access to their system; and most organizations use core inpatient and outpatient systems from different vendors, which requires both back-end interfacing/interoperability work, along with an access bridge or mechanism of some sort. In most cases, this is a physician portal, though it can also be a single-sign-on mechanism.

And then there is the HIE option, which many organizations are beginning to develop. At the same time, hospitals and health systems are also dealing with a diversity of physician relationships along a spectrum from salaried physicians in “captive” medical groups to affiliated physicians with staff privileges and beyond, to community-based physicians who might occasionally refer individual patients for inpatient care. And then, of course, some hospitals are standalone facilities, while other organizations are multi-hospital systems of various types, all with individual demographic, geographic, and cultural situations.

THE PROBLEM IS THAT THE CENTERS AREN'T PROVIDING PHYSICIANS WITH ANY INTEROPERABILITY SOLUTIONS. WE REALLY WANT THEM TO BE A PART OF OUR COMMUNITY, TETHERED TO A FULLY INTEROPERABLE SYSTEM.-PAUL CONOCENTI

Given all this, it should come as no surprise that there is no single “automatic” answer to the question of how to optimize the physician navigability issue. But CIOs and CMIOs from diverse organizations are moving forward on physician connectivity through various approaches. For example:

At Parkview Medical Center, a freestanding, 350-bed community hospital in Pueblo, Colo., Vice President and CIO Steve Shirley and IT Director Paula Oreskovich have outsourced all the interfacing/interoperability work involved in connecting the hospital's affiliated physicians with the facility to the Warminster, Pa.-based MobileMD, which offers interoperability and HIE solutions. From his perspective, Shirley says, outsourcing the interfacing/interoperability work to an outside vendor has averted the need to hire at least two full-time employees to his very small IT staff, particularly as his organization makes the shift in the next couple of years from an older version of the core EMR from the Westwood, Mass.-based Meditech to a newer one.

At the Worcester, Mass.-based UMass Memorial Health Care, a seven-campus integrated health system, Senior Vice President and CIO George Brenckle, Ph.D., has focused his efforts on the ongoing development of a dashboard that allows all types of physicians, whether from among the system's 1,500 salaried physician organization, or from among about 1,000 community-based physicians, to view the entire patient record across multiple systems. These include the Malvern, Pa.-based Siemens Healthcare's Soarian system (inpatient), and the Chicago-based Allscripts’ system (outpatient). Brenckle and his colleagues are using the Chicago-based Initiate Systems and the Pittsburgh-based dbMotion, which have developed a community-wide dashboard for patient information for physicians, for that capability. Working with all those vendors together in a collaborative fashion, Brenckle says, “We've created what we call a connected healthcare community.”

At the Anne Arundel Health System, a 350-bed community hospital organization in Annapolis, Md., Vice President and CIO Doug Abel has led the creation of a Web-accessible, single-platform, community-wide EMR (founded on the core EMR from Epic). Rather than a portal per se, Abel explains that his organization's platform allows direct dial-in to the EMR, in a community in which no more than about 20 percent of affiliated physicians have their own office-based EMRs.

The CMIO-CIO: A Special Perspective

George Reynolds
George Reynolds

When it comes to facing the challenges of optimizing the end-user computing experience of practicing physicians, George Reynolds, M.D., finds himself in a very unusual position these days. Until this spring, Reynolds was both a practicing pediatric intensivist, and the chief medical informatics officer, at the 145-bed Children's Hospital and Medical Center in Omaha. Then, Children's CIO left the organization, and Reynolds was tapped to take on the CIO role, while being asked to retain his CMIO position as well. Not surprisingly, he found it impossible to remain in clinical practice; but, having been with the organization in some capacity for more than 14 years, he finds himself with a degree of credibility among the organization's physicians that many CIOs (and even some CMIOs) would envy.

Still, Reynolds, like all CIOs, finds himself challenged to truly optimize physicians’ computing experience, amid a welter of conflicting demands on his priority list. He is also discovering that there is no “silver bullet” for solving the physician navigation problem. And like his fellow CIOs, he is working through a thicket of time, staffing, and funding resource challenges, as well as issues around physician preference, infrastructure management, and data security.

Omaha Children's has been live with Sunrise Clinical Manager from the Atlanta-based Eclipsys Corp. for about seven years; and has been live with the core ambulatory EpicCare EMR from the Verona, Wis.-based Epic Systems Corp., for a few years, across two different pediatrician groups (whose numbers total about 170), both of which have close ties to the hospital. But there are a number of organizational complications, including the fact that both local pediatrician groups have dual affiliations, with Omaha Children's, and then with one or the other of the two medical schools in Omaha. And then of course, there are the remaining 325 or so community-based physicians who are not members of either of the two closely linked groups, and who have a variety of EMRs (or none) installed.

The hospital's bridging capabilities, Reynolds reports, include a physician portal that allows doctors to open up either system (Eclipsys or Epic) and see data from the other IS, as well as the hospital's document imaging system and PACS (picture archiving and communications system); and a “nascent HIE in which virtually everybody in Omaha is involved”-the Nebraska Health Information Initiative (powered by the San Jose, Calif.-based Axolotl Corp.). In addition, Reynolds and his colleagues have deployed the single sign-on/context integration solution from the Andover, Mass.-based Sentillion Inc. (recently acquired by the Redmond, Wash.-based Microsoft Corp.), which he says has strongly boosted physician acceptance.

Still, even with everything that's been accomplished so far, Reynolds says, “We'd like to think that we've made things pretty easy for physicians, but just recently, I put a survey out again that we send out to the physicians online about every 18 months, and when I asked them questions about satisfaction, I got a fair amount of agreement with the statement, ‘The single biggest frustration for me is the lack of integration between the systems.’ So it's still an issue for us, and it's something we're still working on.”

Vinay Vaidya
Vinay Vaidya

Working through a complex hospital-physician group IT situation, Peter D. Stetson, M.D., CMIO, and Richard U. Levine, M.D., president and chairman of the board, of ColumbiaDoctors, the Physicians and Surgeons at Columbia University, a 1,200-salaried-physician multispecialty group practice in New York City affiliated with New York-Presbyterian Hospital/Columbia University Medical Center, have implemented a single-sign-on capability to help their physicians navigate a complicated computing environment. That environment encompasses Allscripts (ColumbiaDoctors’ core outpatient EMR), the Atlanta-based Eclipsys’ Sunrise Clinical Manager system (the hospital organization's core inpatient system), plus a legacy homegrown inpatient-outpatient EMR at the hospital, and numerous specialty systems also in use at the hospital. ColumbiaDoctors, Stetson and Levine note, is among the multispecialty groups in the vanguard in terms of working with Allscripts and Eclipsys (which announced in June that they would merge) on enhancing the interoperability between the companies’ core EMR solutions.

SOME CONFUSION IN A CHANGING LANDSCAPE

Inevitably, the process of optimizing end-user physician navigation is evolving within a complex and shifting operating environment. For example, Paul Conocenti, senior vice president, vice dean, and CIO at the 602-bed NYU Langone Medical Center in New York, notes that the work that he and CMIO Peter Kilbridge, M.D., are helping to lead around interoperability and physician computing navigation is running into confusion around what kind of role will be played by the regional extension centers being set up under the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act.

“We'll have to deal with the extension centers basically competing with us” in the New York metropolitan area, Conocenti says. “But the point is that institutions like us with large, voluntary-based communities of physicians, are finding that there is confusion over what the extension centers are reaching out to offer physicians, and what we are offering them. The problem is that the centers aren't providing physicians with any interoperability solutions. We really want them to be a part of our community, tethered to a fully interoperable system,” he says, “and [the extension centers] are out there offering small, non-interoperable solutions.”

There is also a lack of consensus on the value of the various bridging solutions being applied to the core challenge of physician computing navigation. Not everyone is enamored with the physician portal as a core solution, for example. One portal-naysayer is Bob Sarnecki, vice president and CIO of the 345-bed Phoenix (Ariz.) Children's Hospital. “We're not seeing that portals have really created big benefits yet,” says Sarnecki. Instead, he and CMIO Vinay Vaidya, M.D., say they are confident that choosing the Tap and Go single-sign-on authentication solution from the Andover, Mass.-based Sentillion Inc. (whose acquisition by the Redmond, Wash.-based Microsoft Corp. was completed in February). Tap and Go, a badge-based system, is providing the core of what physicians need to navigate between and among clinical information systems.

I WOULDN'T CALL IT AN OVERSIMPLIFIED STATEMENT THAT CONNECTING DOCTORS IS IMPORTANT; THE FUNDAMENTAL PRINCIPLE IS TO ALLOW PHYSICIANS TO BE ABLE TO TREAT THEIR PATIENTS WELL.-PETER KILBRIDGE

As Vaidya puts it, “Given the surge in the past few years of demands to address patient safety, quality, efficiency, and so on, you have to shift through what the priorities are for your hospital, and come back to focusing on your mission and vision for the organization.” Rather than investing large amounts of time and money in a portal, Vaidya says, a quick-navigation solution is what Phoenix Children's physicians most want and need right now.

ABOVE ALL, STAY FOCUSED

In the end, all those interviewed for this article agree on one thing: staying focused on one's overall strategies around physician connectivity is vital. “I wouldn't call it an oversimplified statement that connecting doctors is important; the fundamental principle is to allow physicians to be able to treat their patients well,” says NYU's Kilbridge. “But,” he quickly adds, “everyone is caught between some sometimes-conflicting incentives.” And, says Conocenti, “Everyone's going to deal with a duplicate record. And I would imagine that every CIO will face issues around that, including around security and confidentiality, and around issues of trust.”

Doubtless, the landscape of connectivity and navigation will evolve considerably in the next few years. On the other hand, everyone interviewed for this article agrees, CIOs and CMIOs who wait that long to implement solutions in this area are going to find themselves and their organizations at the back of the pack when it comes to finding their way forward in this tricky-yet critical-region of healthcare IT.

Healthcare Informatics 2010 October;27(10):10-15


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