The Obama administration’s huge funding effort to create a nationwide network of interoperable electronic health records (EHRs) has been called the biggest thing that’s ever happened in health information technology.
In fact, the American Reinvestment and Recovery Act of 2009’s HITECH Act, which promises to spend close to $20 billion on the use of technology in healthcare, has even been compared to NASA’s manned spaceflight mission to the moon in the 1960s.
The federal government will offer Medicare and Medicaid bonuses to physicians and hospitals that demonstrate "meaningful use" of interoperable, certified EHRs starting in 2011.
But converting patient records from paper to electronic is only half the battle. On both the clinical and administrative fronts, healthcare providers face daunting knowledge management challenges in bringing together information from legacy, siloed departmental systems and from business processes traditionally done on paper.
For a number of reasons, the healthcare provider setting has lagged behind other industries in deploying enterprise content management solutions, experts say.
"The sheer complexity of the healthcare setting is off-putting," says Alan Pelz-Sharpe, a principal at CMS Watch covering enterprise content management technologies. "Joining up the clinical and administrative, not to mention the insurance part, is a spectacular challenge."
A hospital has many small departments and people don’t tend to think outside their department, he says. Deploying enterprise content management solutions is difficult when there are so many interlinking elements in the healthcare chain, and nobody really owns the overall process from beginning to end. "There is usually not one unifying solution," Pelz-Sharpe says, "but lots of departmental solutions."
Strategically, some healthcare providers have looked for a universal system to organize content, but the fact is they have so many IT systems implemented that many have backed off and reverted to pilot or departmental systems, says Karen Strong, a director of the Houston-based Gimmal Group, a consultancy that helps clients with enterprise content and records management implementations.
But the mindset in healthcare is changing. Strong says, "They are starting to combine structured and unstructured data to begin painting the whole picture. They have a lot of drivers in terms of cost containment pushing them to embrace a culture of information management."
Despite the challenges they face, the following examples illustrate how some healthcare IT leaders are approaching the content management problem. Some are indeed tackling departmental or individual pain points, but as their stories suggest, once a solution proves itself, it often spreads to other areas of a hospital or health system.
Integrated imaging solutions
Not entirely paperless, but "paper light" is the term Cathy Fuhrman’s team has coined for operations at San Diego-based Sharp HealthCare, an integrated delivery system with four acute-care hospitals and three specialty hospitals. Fuhrman, manager of information systems, and her staff have worked diligently over the last five years to integrate Hyland Software’s OnBase imaging solutions with the health system’s major financial and clinical applications.
"With the use of EHRs becoming almost mandatory, there is a need to supplement them with solutions to store and pull paper records, because there is always paper in the system," says Fuhrman.
OnBase is integrated into applications to link documents that originate outside those systems, so that clinicians or administrators have access to them from within line-of-business applications. One example is in routine pre-anesthesia evaluations before elective surgeries. Referrals are faxed to the hospitals, along with relevant medical information. Then the patient comes in for a meeting and physical exam. Previously kept in a stack of paper files, those results are now all stored in OnBase and available to the surgeon at the click of a mouse.
When she talks to other executives in the field who haven’t made as much progress on integrating paper-based documents, Fuhrman says they seem to think it has to be a "big bang" solution that costs a lot of money. "We started with a low-cost solution in the claims department of our HMO, and once we saw that it worked, we rolled it out incrementally to other departments," she explains.
Collaboration tools speed decision-making
The great promise of the push for electronic health records is not just the efficiency of recordkeeping, but that it will actually lead to better care. Providing clinicians with decision support information ranging from the latest drug information to best practices is a part of that effort, but also a major knowledge management task. Both safety concerns and pay-for-performance programs from insurers are encouraging hospitals to develop decision support tools.
For many years, Boston-based Partners Healthcare has been an innovator in the use of clinical decision support tools to remind physicians of best practices at the point of care. But until four years ago, the Partners system, which includes primary care and specialty physicians, community hospitals and two academic medical centers, faced bottlenecks in building consensus among clinicians for updating its decision support content.
"We had these leading-edge tools to help clinicians with decision support and patient safety, but there was not a parallel environment for updating the content in the repository," explains Tonya Hongsermeier, principal informatician at Partners. It was difficult to track the files that produced the results. They could be in a paper filing system or in someone’s e-mail, she says. People would go back to look up why a certain decision was made only to find the lead person on that panel left the organization a year ago.
"We wanted a better way to capture how the decisions were made, and what they were based on," she continues, "and we wanted a more convenient way for people to come together to make the decisions, a better collaboration tool."