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Creating the Clinical IT Model

September 28, 2009
by Frank Clark, Ph.D.
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An academic medical center finds a way to let physicians access information in any care setting

The oldest medical school in the South, the Medical University of South Carolina (MUSC) operates as a freestanding, full-service academic medical center. The campus encompasses four hospitals (an adult, a children's, a psychiatric and a cardiovascular/digestive disease facility) as well as a Veterans Administration Medical Center facility.

MUSC was an early adopter of health information technology, and like most academic medical centers, still operates under a “best of breed” IT environment; doing business with many vendors and not having much leverage with any. The organization accumulated more than a decade of experience with a clinical data repository (CDR) and a clinical results viewer (CRV) - the Oasis open systems technology tool kit technology from Telus Health Solutions.

An ambulatory EMR was installed in the mid-'90s, but failed to gain much use beyond primary care physicians. Document imaging, laboratory, pharmacy, PACS and radiology systems for radiology and cardiology were implemented by the early 2000s. By 2004, the clinical IT momentum had stalled, and implementation of the more advanced point-of-care clinical systems (nursing documentation, order management, bar code medication administration and physician order entry) had not yet been undertaken. And there was very little integration of outpatient and inpatient clinical data. MUSC's clinical environment is a closed staff model; the more than 1,000 practicing physicians are employees of the organization. Some caregivers only see patients in clinics, some see patients only in hospitals, and some see patients in both care settings.

As CIO, it struck me that the organization had the opportunity to create an IT environment that reflected the clinical environment, thus providing caregivers easy access to patient information, regardless of the care setting in which it was captured, and offered our patients a seamless care delivery system. When I put this vision in front of the MUSC IT Governance Committee, they agreed. Plans were set in place in 2005 to create a clinical IT model that scaled across the inpatient and outpatient care settings. We felt that providing caregivers with timely access to clinical data - regardless of where it was captured - would improve the quality, safety, and efficiency of care.

Our initiative to create an enterprise clinical IT environment was expected to take three to four years. We started in mid-2006 and dubbed the initiative eCareNet.

Our caregivers liked the Oasis CDR/CRV functionality and its presentation. Its open system feature and development toolkit gave us the flexibility to react quickly to necessary changes and provided the critical mass around which we felt we could aggregate all clinical data. The CRD/CRV was becoming the center of our clinical IT universe.

One of our first steps was performing a gap analysis of what clinical IT functionality we had already installed and what we still needed. Our plan was not to obtain a vendor's stand-alone niche solution, but rather to acquire pieces of robust functionality or technology engines that would scale across departments, services lines, and care settings. In the inpatient setting, we expected to acquire functionality that would give us a “closed loop” medication process. That process would require an eRx system, clinical documentation, medication administration, and physician order entry. The eCareNet project called for us to obtain functionality module upgrades (and/or acquisition of additional systems/modules) touching many phases of clinical care across myriad settings, including:

  • Complete revamping of the clinical systems infrastructure

  • Replacement of pharmacy system, nursing documentation, ED patient tracking boards and clinical documentation

  • Replacement of the surgery scheduling and OR management system

  • Anesthesiology documentation

  • Upgrade to existing outpatient EMR functionality and infrastructure

  • Bar coded medication administration

  • CPOE

  • Upgrade to existing CDR and CRV

  • Upgrade to PACS and voice recognition implementation in radiology.

Much of the advanced point-of-care technology was obtained from McKesson, the OR/Anesthesiology systems from Picis and upgrades to PACS from Agfa. However, it was the Oasis development toolkit that would knit all of this functionality together around the CDR/CRV.

The out-of-pocket expenses (hardware, software and implementation services) for these additions and improvements were approximately $30 million, with the five-year total cost of ownership estimated at around $37 million. The project timetable reflected the desire to complete implementation of these core systems within three years. This would, to a degree, possibly establish a closed-loop medication process in the hospitals, and subsequently, a highly desirable market position though safer care.

The goals for the MUSC eCareNet project mirrored the Institute of Medicine's eight core care delivery functions for an EHR. We now feel that most of the functions will be part of the meaningful use requirements from CMS.


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