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Urgent Care: CIOs Struggle with the ED Integration Issue

November 28, 2010
by Mark Hagland
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Will Standalone Systems Hold up Under Meaningful Use


The current landscape around meaningful use requirements under the HITECH Act is forcing CIOs and their colleagues to confront a stark choice between two strategies-one being maintaining a best-of-breed emergency department (ED) clinical information system, and interfacing it to their core inpatient electronic medical record system; and the other being to pursue a uniform core-clinical strategy, even if that means ripping and replacing a best-of-breed ED system with an ED module from the core-clinical vendor. The debate over this choice reflects the broader clinical IS challenges facing CIOs and other healthcare IT leaders today.

Chuck Podesta, senior vice president and CIO at the 562-bed Fletcher Allen Healthcare in Burlington, Vt., has faced what many CIOs might consider a potential “nightmare” scenario: he's ripped out a popular best-of-breed emergency department (ED) information system and installed the ED IS module from his core clinical EMR vendor (the Verona, Wis.-based Epic Systems Corp.). Facing a “Sophie's Choice”-esque conundrum of a potential emergency physician mass revolt, versus interfacing hell in perpetuity, Podesta swallowed hard and sat down with the physician leaders of his ED, who, in his words, “really stepped up to the plate,” and agreed to make the change to the core clinical-based ED module.


And even though the hospital's 30 ED physicians' “productivity tanked, as we had expected,” by the time the Epic system went live in June 2009, “We had worked very hard with them as part of the Epic go-live process, and in fact went live in the ED 72 hours in advance of the rest of the hospital,” to help smooth the transition, Podesta reports. What's more, he says, what emerged was the realization that an absolutely key factor involved in ED physicians' loss of productivity (which was adding an hour or more onto their already very long workdays, in the busy, 60,000-visit ED) was the length of time needed to document in the new system. “How we finally got over that hump was by bringing on the Dragon [NaturallySpeaking] speech recognition product from [the Burlington, Mass.-based] Nuance [Communications Inc.], which bolts on very nicely to the Epic ASAP ED product, and which works very nicely with the templates in the Epic system, and takes about a half-hour to learn,” he notes.

With that technology addition, Podesta was able to overcome an intense ED physician satisfaction challenge, and move forward to streamline the ED-to-inpatient documentation and clinical workflow continuum through the implementation of a single core clinical vendor across both the ED and inpatient spheres.


Chuck Podesta
Chuck Podesta

The question facing Chuck Podesta and his colleagues at Fletcher Allen is one being replicated across the country, as CIOs, clinician leaders, and clinical informaticists nationwide are confronting the best-of-breed-versus-core-clinical-vendor choice in its most dramatic, concentrated form, at a time of heightened tensions. With the data collection and reporting requirements for meaningful use coming out of the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act, the stakes around that question are higher than ever. What's more, since so many hospital organizations around the country implemented best-of-breed ED clinical information systems before they implemented full EMRs, but are now rushing to implement EMR and computerized physician order entry (CPOE) to comply with meaningful use, their leaders face a stark choice between potentially alienating their ED physicians and living in interfacing hell for the foreseeable future.

Scott MacLean
Scott MacLean

At its core, the debate centers around two potentially conflicting imperatives in healthcare IT right now, the mandate to achieve meaningful use under the HITECH Act's provisions, and the need to satisfy the needs of end-user physicians. Given the intense pace and unique requirements of the ED, those imperatives are ending up in conflict more often than not these days. Consider the following:

  • A considerable plurality of U.S. hospitals have best-of-breed ED systems that were implemented some time before those hospitals implemented full electronic medical record/electronic health record (EMR/EHR) systems in their inpatient facilities.

  • A large plurality, if not an outright majority, of U.S. hospitals are rushing to implement CPOE systems right now, under the HITECH Act's meaningful use requirements.

  • CIOs and their colleagues are discovering that the quality data reporting requirements under meaningful use are turning out to be very rigorous under Stage 1, with a ramping-up of many requirements, including quality data requirements, expected in Stages 2 and 3.

  • Thus, the core-clinical-vendor-versus-best-of-breed-system conflict is erupting dramatically right now, nowhere more than in the ED, where the stakes are among the highest in patient care organizations. The statement made public by the federal government in late September clarifying that ED orders using CPOE for patients who are later admitted as inpatients will count towards the meaningful use denominator in Stage 1, are expected to further intensify the discussion around standalone ED systems.

  • A key point of debate is the degree to which the interfacing required to support an ongoing diversity between ED and inpatient core clinical systems is tenable going forward, with healthcare IT leaders sharply divided on this critical point.

Mark Lemons, M.D.
Mark Lemons, M.D.

Thus, CIOs are faced as never before with a very stark choice, if they have disparate ED and inpatient clinical IS, as to what to do. Not surprisingly, this issue has now emerged as an intra-institutional controversy nationwide, with some CIOs taking one side and some taking the other, depending on their organizations' IT history, current situation, vendor relationships, finances, and other factors. The issue is made more wrenching because all those interviewed for this article concede that, by and large, the best-of-breed ED IS products are considered superior in functionality to core-clinical-vendor ED modules. Yet the level and intensity of interfacing required to maintain a best-of-breed ED IS in the face of the meaningful use requirements is weighting the equation very strongly in favor of a core-clinical choice on the part of most of those interviewed for this article, with strong exceptions.


In contrast to the views of Chuck Podesta and others like him, there are CIOs and clinician leaders who say that, no matter what specific choice they make around their ED system, they face a future of intensive interfacing in any case. Such is the situation at the 250-bed Newton-Wellesley Hospital in Newton, Mass., say CIO Scott MacLean, and chairman of the emergency department Mark Lemons, M.D. MacLean and Lemons point out that their organization is a part of the vast Partners HealthCare system based in Boston, whose several hospitals are working through very intensive issues around the existence of disparate clinical and other information systems in a multi-hospital system that has grown through mergers and acquisitions. Indeed, IT-wise, Partners is a patchwork quilt of eight fully owned acute-care hospitals, not including rehab and psychiatric facilities, and affiliated organizations, with a tremendous variety of clinical and other information systems.

Currently, MacLean reports, Partners has embarked on a system-level initiative to look at the extent to which the organization should pursue a strategy of drawing down on its IT heterogeneity. For the time being, though, MacLean and Lemons see interfacing as their lot no matter what happens at the system level. At Newton-Wellesley, the core inpatient EMR is the Meditech Magic 5.62 system from the Westwood, Mass.-based Meditech Corp.; the hospital's ambulatory EMR is a self-developed system; and its ED system was originally from a company called Ibex, which was acquired by the Wakefield, Mass.-based Picis, and which in turn was recently purchased by the Eden Prairie, Minn.-based Ingenix.


Given that landscape, MacLean says, “In general, we would expect to support the interfacing necessary from the ED documentation system, which is a specialty system as far as we're concerned, to the inpatient EMR system. It's not insurmountable, but there are technical and time challenges involved. And there are hand-off issues between our ED system and our inpatient system, and of course, to referring physicians. We're trying to work on those issues.” But, he emphasizes, “It's much more about throughput than it is about interoperability.”

Jorge Grillo
Jorge Grillo

Says Lemons, “If I were to rip things out and go to the LMR product [the internally developed ambulatory EMR system] or Meditech product, which weren't designed for the ED world, that would be extremely taxing for both the physicians and nurses. This [Ingenix] product is extremely customized for emergency physicians and nurses. Way back when, in 2002-2004, when we looked at what was available, and sent some of our ED physicians to an annual conference of emergency physicians from Pennsylvania, and they felt strongly that the [then-]Ibex product was superior, and that Meditech's ED module was years and years behind. In fact, when the people at Meditech learned that we had chosen Ibex, they wanted us to help them develop a Meditech ED system, to improve theirs as a beta site,” he says. “But we felt that would cripple our flow.”

So, for the time being, interfacing is the future at Newton-Wellesley. Asked how onerous the ED-inpatient interfacing is, MacLean scores it as a “five” on a scale from 1-10. “It's not horrible,” he says. And for him and his colleagues at their organization, it's worth it.

Some CIOs might go even further. Jorge Grillo, CIO at Canton-Potsdam Hospital, a 100-bed, freestanding community hospital in Potsdam, N.Y., says, “I'm a CIO who has been in best-of-breed environments for over a decade; and interfacing is just a fact of life. And really, what it comes down to, in most cases, is not an interfaced versus non-interfaced approach, but more of a dollar approach. You've got small hospitals, rural hospitals, who have to do an ED system in order to achieve meaningful use. Eight percent of your outpatient orders have to come from someplace. And your biggest outpatient line is usually ED. So that means your ED docs have to write electronic orders.”


Grillo uses the ED IS product from the best-of-breed vendor, Medhost Inc., based in Addison, Texas; and he interfaces that system to his organization's current version of the Meditech Magic product. Looking at the choices involved, he says, “There are a lot of pros and cons involved; but the hold-up or challenge should not be the interface. Interfacing is a way of life in every hospital in the United States; that should be the last argument anybody has. I think the argument needs to be, what is the right business decision for us? And making good IT business decisions is always a challenge,” he adds.


Todd Rothenhaus, M.D.
Todd Rothenhaus, M.D.

The arguments of Grillo, MacLean, and Lemons, regarding interfacing in their operating environments will doubtless resonate with many of their colleagues. Still, the majority of CIOs interviewed for this article are declaring themselves on the side of full integration coming out of a core-clinical strategy.

Among these is Todd Rothenhaus, M.D., senior vice president and CIO at the six-hospital, 1,500-bed Caritas Christi Health Care System, based in Brighton, Mass. Rothenhaus, who speaks with special authority as a former practicing emergency physician, believes that “This is the biggest philosophical issue now for emergency departments. I actually chaired a taskforce on ED implementations for ACEP,” he notes, referring to the Irving, Texas-based American College of Emergency Physicians. And, though he notes that “I have many, many friends in the ED information systems industry now, and some have written really wonderful, intuitive software, and many are physician entrepreneurs; and it's always a little bit of a shame that some of the opportunity for those vendors will be reduced. I've felt for a number of years that the trend would be towards core clinical systems.”

Sue Schade
Sue Schade

What has really shifted is the fundamental landscape around ED operations, Rothenhaus says. “If you ask anyone outside the ED, the vast majority of people would say the ED should be on the hospital information system, while the vast majority of ED physicians still want best-of-breed,” he says. “But an important element in all this is the wireless environment, with ARRA-HITECH becoming a game-changer. There are literally 4,000 small- to medium-sized hospitals out of the 5,000 out there,” Rothenhaus notes. “And I think that what sort of emerged is that until the inpatient space became wired, there was no compelling value proposition to be on those systems. And anyone can say we can integrate best-of-breed systems into the hospital, but that was really laboratory and radiology systems and a few others. But the concept of having a very seamless flow of information, exactly what the patient got downstairs, and have that all be integrated, it's a lot harder to achieve now. And now you have a mixed cumulative denominator going on with regard to the meaningful use requirements.” So the logic around a core-clinical strategy just becomes indisputable, from his perspective.

Doug Abel
Doug Abel

Some CIOs frankly concede that they're still trying to sort out the ultimate logic of all this. Sue Schade, vice president and CIO at Brigham and Women's Hospital in Boston, is one of those. Her organization has had a self-developed ED order entry system since 2001, while she and her colleagues are currently implementing the physician documentation component of that system. Their ED system is interfaced to their core EMR, which was self-developed years ago.

Meanwhile, like her colleague MacLean up the road, Schade, one of several CIOs of the hospitals in the Partners system, is trying to harmonize her organization's individual needs with those of their overall system. “The broader context for us is an effort towards going down a common clinical systems path at Partners,” she notes. “We have order entry and tracking in already, but if you went into our ED area, you'd see that it's not optimized or ideal for them yet. So we've been trying to figure out what to do with that for an extended period of time. Do you take your ambulatory system and move it into your ED? Your inpatient system and move it into the ED? Or go best-of-breed?” Given the combination of elements involved-some self-developed systems, the ED-core-clinical question, and the need to move forward with her colleagues on system-wide strategies-at times the issues become nearly Rubik's cube-like, she concedes.

Doug Abel, CIO of the 320-bed Anne Arundel Health System in Annapolis, Md., has the good fortune of working in a somewhat less complicated operating environment. His organization switched from Meditech to Epic as its core clinical vendor, implementing Epic's ED module at the same time as its inpatient component, last December.

“Our overall goal wasn't just integrating the hospital,” Abel reports. “It also gave us the opportunity to integrate with the physician practices in the community. And to have the ED docs on a separate system just breaks that continuity of care. The thing that strikes me is that, for most of us, 50 percent of our hospital admissions come through the ED,” he continues. “So if you recognize that, you recognize the need to integrate data, to integrate the ordering process with the pharmacy, and with the flow of the patient from the ED up to the floor. And that's just so difficult to do in a non-integrated environment. And if you're trying to integrate out into the community, the community physicians really need to be a part of the integrated process, he concludes.


Every one of the CIOs interviewed for this story agrees that the issues are complex in this area, and that the choices can be wrenching. They also agree that different hospital organizations are inevitably going to make different choices, based on their operating environments, circumstances, histories, and cultures. Caritas Christi's Rothenhaus offers this counsel to his fellow CIOs: “My advice is to put together a governance committee that includes all physicians, including ED physicians, in the organization,” he says. “ED physicians must be included, as well as nursing leadership in the ED. And I think the CIO has to make a very good decision on how a best-of-breed ED system can be integrated into the rest of the hospital system. The CIO's responsibility is to present the best integration solution; and the clinical group needs to decide whether or not the integration is good enough to a) support care process transfer from the ED to the inpatient space and to b) represent a strong enough aggregation of data to meet meaningful use. And the answer could be yes. What will be important is for the CIO to be transparent about the complexity of integration going forward.

Healthcare Informatics 2010 December;27(12):10-16

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