Two Solutions, One Answer
By Sandra Nunn, MA, RHIA, CHP

Solution One
For more than four decades, healthcare has been trying to reach full computerization of its clinical, administrative, and financial functions through purchase or development of computer systems. These systems have ranged from fully integrated product lines to best-of-breed solutions designed to satisfy the desires of particular segments of healthcare organizations (eg, radiology, HIM, and nursing). Just at the moment when a bewildering array of healthcare software products and systems stood to confuse even the most veteran information systems (IS) departments, the Web arrived and added a whole new twist to the equation, making previous dreams potential realities.

The current dilemma of most healthcare IS departments is that they have already invested in a vast number of legacy computer products. This state of affairs arose from efforts starting in the 1960s when healthcare began a pattern that persists to this day: the borrowing of business solutions from other industries.

During this time, healthcare borrowed the concept of computerizing business and financial system functions by acquiring best-of-breed IS solutions to streamline its financial processes. A best-of-breed solution can be defined as an IS product that is specifically customized to meet the needs of a particular venue, often written in proprietary code and then heavily marketed to the healthcare niche (eg, labor and delivery and surgery scheduling). The product is usually one that has successfully automated other clients in the niche market and has a reputation for being an expert system that is appealing to the customer and meets the customer’s specific needs.

With this move, healthcare made an almost irrevocable decision to buy stand-alone systems adapted to its different modalities: business management, information management, care delivery, and managed care. Each of these modalities contained subentities that elicited even more customized development (eg, coding systems, radiology applications, quality management products, and decision-support systems).

Organizations that take this approach, however, do face certain problems. “First, it can be very expensive to build and maintain all the required interfaces between the systems that need to exchange information,” says Bruce G. Lemon, vice president of First Consulting Group. “Second, you may have to perform functional workarounds when the software does not interface easily or provide the desired workflow. Third, smaller niche vendors have a tendency to either go out of business or be acquired.

“Either case can cause significant disruption and require investment to replace the system,” Lemon continues. “Finally, it becomes more challenging to manage multiple vendors and get them to perform up to expectation. When things go wrong, there is a tendency to point the finger at the other vendor vs. solve the problem.”

The Arrival of Accountability
These systems served healthcare well enough through the ’60s and ’70s when it operated on the simple principle of higher patient volumes translates to greater revenues with the ability to pass all costs and hefty profit margins onto healthcare’s payors.

After the arrival of Medicare in the ’60s, the government paid out whatever it was billed. However, just when things were getting especially rosy, the government, concerned about soaring healthcare costs, introduced the concept of a prospective payment system with something called diagnosis-related groups in the early ’80s. This system introduced the first requirement in healthcare to exert cost control with the requisite need for sound, integrated, instantly accessible information.

Suddenly, healthcare organizations began to search for ways to integrate their disparate, best-of-breed systems. One of the first efforts to integrate systems was the development of a master patient index complete with a unique patient identifier that would tie clinical and financial information and allow all patient encounters to collect under one reviewable number.

The introduction of a common patient identifier was followed by the first successful interface programming—ie, programmers specializing in creating code that would allow two stand-alone, best-of-breed systems to communicate. Along came another best-of-breed solution: interface engines, or chunks of programming designed to act as two-way translators between disparate systems’ languages.

Parallel Development
Concurrently, prospective payment systems and other events (an emphasis on patient safety) were pushing the development of IS that could support better patient care at lower cost. Vendors, anxious to extend their penetration into healthcare, began to offer the first clinical applications. These products proposed to automate bits and pieces of the clinical system from computerized operating room systems to voice-recognition systems customized for radiology or the emergency department. Other forward-looking vendors began to offer clinical systems that could provide more than one function, but frequently developed only one or two functionalities well.

The vice of tightening reimbursement continued to squeeze healthcare administrators who simultaneously faced constantly rising IS investment costs without any real return on their investments. During the first flush of investment in IS, healthcare administrators were content with the simple returns of automating paper-based systems and eliminating the overhead of clerical staff. Forced to consider falling revenues and the rising cost of IS development and maintenance, healthcare administrators began to insist on accountability and management of their IS resources. From this effort began the management of information as a strategic resource.

Solution Two
As the ’90s approached, healthcare administration took a step backward from the headlong rush to computerize its disparate functions and began to look for a more systematic approach that might reduce cost and allow for more integrated solutions.
Jerry Shultz, vice president of sales and marketing for NextGen, is a veteran of the tug-of-war between integrated and best-of-breed solutions. He is proud that his organization, initiated in 1994 to provide physicians with practice management solutions, has survived and thrived in turbulent times for healthcare. Beginning with an enterprise practice management product, NextGen now offers a suite of products designed to facilitate the delivery of high-quality care at the lowest possible cost in the physician practice environment.

Shultz recalls that the “trend originally was toward integrated solutions.” Healthcare administrators who were happy with their financial and accounting IS tried to add on clinical functionality with vendors with whom they were familiar. Shultz notes that “integration is always best,” but that some vendors were not equally strong in the financial and clinical domains. Therefore, market dynamics often drove healthcare administrators toward best-of-breed solutions.

However, to some, integration remains the best solution, eliminating the need for duplicative log-ins, security, and administration. With integration, data sharing is easy and enhancements to one part of the system can be of value to all. Schultz explains that “granular data” would be possible and accessible at any level, a feat impossible under best-of-breed solutions. This strength would be enhanced if the physician practices in question were owned by a common organization. He cites the Health Insurance Portability and Accountability Act (HIPAA) as an example, stating that the tables to accommodate HIPAA functionality were added just once and were of value to all components of the system.
That’s not to say integration is without its faults. According to Lemon, “While some vendors have come a long way over the past couple years with the development of their software, certain components may not have the functionality that some of the smaller niche players can provide. If you go with the integrated approach, you may have to sacrifice some ‘nice’ to have functionality.”

One Answer
In recognition that healthcare organizations are involved in many types of strategies to achieve electronic medical records (EMRs) and that they are at different points on the path to achieving a fully automated solution, CareTech Solutions offers support no matter what the healthcare entity decides to select as its answer to an EMR. Based in Troy, Mich., the healthcare information technology outsourcing company supports more than 22 healthcare systems and has hundreds of experts in all aspects of healthcare automation to support its clients. CareTech can help outsource IS functions or other functions or can offer expert advice on existing departments. It has more recently begun to offer expertise in the arena, particularly in software selection and document imaging initiatives.

Pat Milostan, CareTech Solutions senior vice president and CTO, notes that “We are vendor-neutral and can offer advice on integrated or best-of-breed solutions dependent on an organization’s requirements.” CareTech queries clients to assess their current processes, reviews their decision-making methods, and translates desires into concrete, documented needs. The client may want to begin with a financial or clinical product, but Milostan notes that there are “vendors out there now trying to intermingle both.” CareTech tries to come up with a best solution for the technology and staffing that must accompany the software and hardware. Questions Milostan frequently hears are: “Do I keep my current legacy system and build on it?” or “Should I stay with my current vendor?”

“You need to look at functionality for success,” Milostan says. “If you force someone into a product without the necessary functionality, the solution won’t work. Technology must be able to grow and change. Companies should be able to deploy new hardware without software upgrades.”

Lemon sees a trend toward integration. “Although the debate [integration vs. best-of-breed] continues, my experience is that a greater percentage of healthcare providers are favoring the integrated approach,” he says. “They recognize that they may, in some areas, be making trade-offs in functionality for the benefit of cost savings and interdepartmental workflow improvement. Many also prefer having a fewer number of partners to work with.”

Cost
Particularly in today’s healthcare environment, cost is a key criterion for system selection. CareTech helps organizations determine what they can actually afford. Milostan poses the question, “If a custom product is really expensive, will you use all of the functionality?” He suggests that organizations look at long-term cost and not just the cost of the immediate acquisition and implementation. “Can you really afford to pay for the services it will cost to maintain the product?” he asks. He does not rule out best-of-breed, highly customized solutions for ancillary departments (eg, radiology and HIM), but cautions that the linkages such systems require to the primary system must be few, noting that “limited numbers of interfaces are manageable.”

He agrees with Shultz that integration is best and states that “your core business solutions are key—ie, your ADT [admit, discharge, transfer] system must be very carefully selected.” CareTech offers clients access to 650 experts who have knowledge of multiple healthcare systems. They offer expertise in vendors and technologies, including multiple document imaging solutions.

HIM’s Focus
An integrated system can greatly affect the HIM department. Milostan cites the benefits of document imaging’s ability to perform many HIM functions, including provision of documents online for analysis, faxing, storing, transferring, or performing record reviews. Each organization has a different culture, and solutions vary depending on whether it’s a university hospital with a residency program or a for-profit system bent on turning a profit to shareholders.

Milostan says the increased interest from enterprises that want to do serious information management is reshaping the integration thought process. He observes that most hospitals are “data rich and information poor.” CareTech Solutions works with administrators and CMOs to provide solutions that allow critical decision-making data to appear in a “dashboard” format in the format the decision maker requires.

The Web
Particularly important has been the arrival of Web technologies in terms of system selection. Milostan remarks that the Web is an “immense change in the healthcare arena. [It can] put information into the hands of physicians anywhere—the best information provided in the quickest, most up-to-date way.”

Milostan feels confident that the EMR will arrive within the next three years, citing the drop in cost as a big factor. He notes that there is no “A-to-Z solution” for everyone, and says that “emerging technologies are pulling it all together.” These new technologies can tweak current technology to push it into the future, making EMRs easier to obtain.

Milostan acknowledges the need for national standards and describes HIPAA as some of the “red tape” the industry needs. HIPAA’s cost will be “enormous, but have long-term value,” but the standards will help the need to integrate multiple vendor solutions. He notes that there is no single vendor solution in spite of some company claims and that all EMRs will be a limited combination of vendor products.

Shultz grants that standards must be employed to reach fully electronic charts capable of interchanging data with other systems. He thinks many of these standards will take effect in three to five years. NextGen is anticipating the future by incorporating pediatric standards from the Centers for Disease Control and Prevention for immunizations and growth charts into its EMR. Acknowledging that SNOMED CT is the future coding language in electronic charts and that the LOINC standards will probably be the gold standard for lab values, NextGen is looking to incorporate those and others as their products evolve.

Shultz sees no limits for the possibilities of integrated, high-speed answers to healthcare’s questions. NextGen has moved into an integrated mode by connecting its suite of products through wireless techniques such as a personal digital assistant that permits physicians and other caregivers to interact seamlessly with the company’s EMR and enterprise practice management solutions. Leveraging Web technologies, NextGen envisions the incorporation of access to expert databases without the physician ever having to leave the electronic chart.

Supporting Milostan’s assertion that fully electronic charts are near, Shultz foresees “real-time, speed-of-light adjudication of claims, instantaneous lab results, anywhere, anytime access to patient monitoring systems.”

With the opportunities afforded by Web technologies and the continuing evolution of clinical products, healthcare administrators may no longer have to choose an integrated product or best-of-breed, but may be able to have an intermingled solution that exactly meets their organizational requirements.

— Sandra Nunn, MA, RHIA, CHP, is a contributing editor at For the Record.

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