Clinical information will have to be computerized before it can be used to manage care systematically, and most healthcare facilities have a long way to go to get their data off charts or clipboards.
But that's only the beginning, say experts on using information in clinical settings. Once computerized, the data have to become part of an overall effort to coordinate the contributions of many departments toward patient diagnosis and treatment.
For example, if pharmacy information is not easily integrated with lab results, medical history or nursing documentation, a doctor might not get a complete picture of why a patient is taking a turn for the worse.
The best approaches to clinical information technology allow data from perhaps dozens of different computer applications to be swapped and sorted as if they came from the same system, says Thomas Handler, M.D., a research director in the healthcare group of Gartner, a Stamford, Conn.-based information technology research and advisory firm.
It's a complicated technical undertaking for healthcare information systems companies, much more extensive than just patching fundamentally different systems together through interfaces. In the past several years, some companies have spent many millions of dollars to rebuild their computer architecture in a bid to tightly integrate specialized applications serving a variety of clinical purposes. The result is a truly workable computerized patient record.
A handful of vendors have made that integration strategy a mark of differentiation in the market. But Handler says the differentiation is beginning to blur as competitors race to retool along the same lines.
"Three years ago there was a clear dividing line between integrated vendors and nonintegrated vendors," he says. "Almost all the visions of all the vendors are coalescing."
The upshot is that "the vision of an integrated CPR is no longer a differentiation," Handler says. "The big difference is who can deliver it when, and how well will it work."
With an integrated electronic record of physician orders and patient treatment data as the technological foundation, IT vendors have big plans to build into clinical care the kind of efficiency that was out of reach a few years ago.
Foremost among the envisioned advances is a combination of physician order entry and a triggering of clinical data and suggested practices in support of ordering decisions.
Computerized physician order entry has attracted a lot of recent attention as a means of preventing medical errors, but proponents also talk up the organizational logic behind getting doctors to enter orders and building an integrated series of communications and responses to the orders.
A physician order "drives a lot of activities throughout the clinical process, and they have to be integrated," says Harvey Wilson, chairman and chief executive officer of Eclipsys Corp., Delray Beach, Fla. "We're just beginning to scratch the surface where the clinician is the primary user of the system and institutes the beginning of a process."
Physicians are regaining control of the healthcare process after years of heavy managed-care intervention, and that changes the priorities of IT, says Paul Taheri, M.D., chief of the trauma burn center at University of Michigan Hospitals and Health Centers, Ann Arbor.
Much of the computerization to date in healthcare organizations has concentrated on the intricacies of insurance reimbursement and on moving patients through a hospital stay, which are important but have little to do with actual patient care, Taheri says. "The core transaction in a healthcare system is still between the doctor and the patient."
All other digitizing of data emanates from that point, he says. And the new approaches of clinically oriented information systems have that in mind not only in physician order entry but in other opportunities to bring discipline, interactivity and efficiency to the many support activities.
Here are some of the more ambitious objectives:
* Reducing labor costs through automation. When orders are entered electronically by clinicians and the results disseminated to the appropriate places automatically, the healthcare organization doesn't need to pay clerks to type in orders or runners to deliver the reports.
* Better use of scarce healthcare professionals. A significant portion of the work day for pharmacists and nurses is devoted to typing orders into pharmacy systems, scribbling clinical notes and counting out medications for patients. Automating those duties allows high-priced employees to spend more time on their essential care-delivery functions, ultimately reducing the number of hard-to-find professionals required to meet a healthcare operation's demands and improving retention rates (See Eye on Info, May 28, p. 32).
* Maximum use of existing assets. When capacity becomes strained in surgery, the intensive-care unit or the emergency department, the usual response has been to seek additional capacity by investing in new construction. But managers often have more capacity than they realize-the existing facilities aren't used to their fullest because of rampant inefficiency, says Mikael Ohman, associate principal with McKinsey & Co. By rethinking key routines with the aid of sophisticated computer management techniques, hospitals can make better use of the current space, he says.
* Productive assimilation of medical knowledge. New medical findings and local consensus on best practices are continually offered for physician consumption, but the information has to be systematically incorporated into the ordering process to have an impact on medical and cost decisions, says William Stead, M.D., a leader in the development of computer systems for medical practice at Vanderbilt University Medical Center, Nashville. Vanderbilt is collaborating with McKesson Information Solutions to make introduction of best practices a simple matter at the point of physician decisionmaking.
* Vigilance against workflow foul-ups. Computers can economize the process of healthcare and inject important information at the point of electronic ordering, but the smooth running of healthcare operations depends on the coordination of many tasks triggered by clinician treatment decisions during the course of a patient stay, says Frank Lavelle, president of Siemens Medical Solutions Health Services Corp. The Malvern, Pa.-based information services business, formerly Shared Medical Systems, introduced a new push last month to computerize the complex interplay of departments and professionals in care delivery (Modern Healthcare, Oct. 29, p. 20). The aim is to synchronize all the activities scheduled on behalf of patients and eliminate the crossed signals that delay treatment and waste resources.
The vision of medical management is tantalizing, but the decisions surrounding it involve financial risk and technological gambles, observers warn.
Prospective buyers of clinical-care IT systems will have to consider not only what they want and can afford but also how the new applications fit into their existing tangle of computerization.
Information systems for reporting laboratory, pharmacy and radiology results are essential components of a clinical-management infrastructure, and healthcare facilities likely have made million-dollar investments in those systems already.
And nearly all hospitals and healthcare networks have workhorse financial and patient-accounting systems, which supply both patient demographic information and the cost data that round out the detail necessary to manage care delivery.
Until the importance of integrating information became apparent, healthcare applications were selected to satisfy a particular department rather than their ability to share and consolidate information with other applications and the healthcare system as a whole.
Sometimes healthcare organizations intentionally chose systems for their individual attributes knowing they had to be brought together as a system through extensive interface development. This so-called "best of breed" philosophy created some major integration problems, says Perry Pepper, CEO of Chester County Hospital, West Chester, Pa.
The same type of challenge was going on at several healthcare information services companies during a period of product acquisition and consolidation in the middle to late 1990s. HBO & Co., now McKesson Information Solutions, acquired more than 20 applications to broaden its product line for the full range of provider and payer operational needs. But then it faced reconciling a hodgepodge of disparate methods for creating, trading and storing data among them.
Now the healthcare industry is about to add a new wave of clinical computerization and with it a potential slew of new integration problems. Companies that have invested in integrating systems through a common computer foundation say their approach is the only one that can work.
For example, Per-Se Technologies markets a broad and interlinked set of applications that was built from scratch around a centralized database, designed to assure continuity of information on an episode of patient care, says Karen Andrews, president of Per-Se's application software division. "It's not bolted together through acquisitions," she says.
In addition to fundamentally identical design among component applications, the benefits of ground-level integration include superior computer response time, says Judith Faulkner, president and CEO of Epic Systems Corp. "In the end, a clinical system will fail because of poor response time, because doctors will not use it," she says. "Then the promise of clinical decision support is unfulfilled."
Working around what's already there
McKesson and Siemens, however, are holding on to an advantage over their competition: the thousands of healthcare organizations that already run their information system products and have an existing multimillion-dollar investment to consider in their future decisions.
So while the two biggest IT companies acknowledge the need for integration of diverse healthcare applications-and are busily developing new product lines with that in mind-they're working to add new clinical computerization to their existing mix in the meantime.
McKesson last year launched development of a new integrated line called Horizon, designed to eventually spread throughout a provider organization but also to connect sources of information from older information systems to hospital users via Web technology.
Siemens is seeking to re-invent itself with a new line of information technology "built from the ground up with workflow at the center of its design," Lavelle says. But it plans to incorporate the workflow software in a series of small steps for existing customers and also try to sell to new customers based on a study of what systems they already have.
Chester County Hospital, one of the first test sites for the Siemens line, is willing to go the gradual route with new technology surrounding the older installed investments, Pepper says. Despite historical difficulties with interfacing disparate systems, "We're beginning to make the machinery work together better than we have before," he says. "This couldn't have been done as successfully five years ago."
Handler of Gartner says provider customers were likely in the past to stay with their current vendors when new technology came along, but the newly appreciated need for tight integration of many applications in a clinical setting is forcing executives to re-evaluate that habit.
"There are more organizations seriously considering bringing in somebody else," Handler says. "Siemens and McKesson have a well-developed vision but haven't delivered on it yet."