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Building the Digital Hospital of the Future

HealthLeaders magazine, December 10, 2009
GIBBS: Right now, the models from the vendor population are two segregated groups that need to come together. You have the groups that are focused on cost accounting and the financial reimbursement aspects of the decision-support spectrum, and you have the vendors that have been on the clinical side. If you want to get to outcomes, you need to put the two pieces together in an integrated format where you can feed from the EMRs to the decision-support tools.

JOSLYN: If you had medication information from your patients, it may not match up perfectly among pharmacies, but you will know a lot about the patient. It's the same thing with claims information. Providers who can see claims across a variety of payers can discern what's going on with a patient. We're going to have to start doing that on the clinical side.

STETTHEIMER: The challenge is the process metrics that we need during the process of care are not there. Let's talk about error rates. There are no definitions that are agreed upon—no platform, no vendor; no one would agree on those precise parameters. It becomes challenging from an analytics perspective to track to those metrics and improve.

GIBBS: Another issue that we don't talk about frequently is the enterprise master patient index. How does one numbering system match up to yours or somebody else's?

MORLEY: Based on where the industry seems to be heading, MPIs will become a critical tool. They will play an indispensable role in providing clinical and reimbursement information.

JOSLYN: We're doing it to some degree now and it is challenging. We have an Epic-to-Epic connection, which is two independent organizations that happen to have Epic that connect to one another. A hospitalist taking care of a patient is able to reach into his system and look at the patient's encounters with an independent physician organization and bring that information into the inpatient situation.

STETTHEIMER: What you just described means you're taking data that's in one EHR and populating another EHR. It's proliferating copies of the data. You potentially could get into the scenario where everybody has copies upon copies of data, and then you get into all kinds of interesting challenges around who has the exact right copy. Why would you want to replicate data like that potentially thousands of times?

JOSLYN: In that particular case, it's not the whole record.

MORLEY: Not to downplay the complexity of managing patient data, but when you apply for a loan at a creditor with whom you've never done business, your bank doesn't send over your entire record and then wait for it to come back with changes. You provide access to certain information upon which the creditor makes a decision about worthiness, loan size, and rate. These organizations are able to pull the information they need in real time because they have invested in the technology and worked out the associated processes.

HEALTHLEADERS: We still have a fee-for-service reimbursement system, so when do you start investing in technologies to prepare for an outcomes-based reimbursement system?

STETTHEIMER: You build triggers into your road map. You may be setting up different scenarios based upon the definition of meaningful use. Do you pull the trigger when the final rule is released? If you're too early, you will incur significant investment and cost before you ever get to a means to recoup it. And the sustainability of that health provider is then going to be questionable.

JOSLYN: But meaningful use is a means to have outcomes management. So those heading down the EMR adoption path are either consciously or unconsciously moving in a direction to be outcomes-based.

GIBBS: We've started to invest heavily in the decision-support system so that we can prepare ourselves longer term to more effectively use the data.

STETTHEIMER: We see the potential for capital freed up based upon a variety of drivers, including meaningful use. But the handle is on the tap; it's not quite turned yet in most cases.

JOSLYN: Our governance board has become much more interested in seeing a return on IT investments. When we began pursuing EMR well in advance of ARRA, our board said, 'We want you to make an attempt at an ROI.' We came up with 20 measures. That forced us down a more disciplined path in those investments because of economic realities constraining capital in healthcare. As things become more of a utility, it's become a cost of doing business.

GIBBS: While capital dollars is one piece, you also have to recognize the significant increase in the operating expense from these projects.

HEALTHLEADERS: If you look at decision support and the amount of data involved, what infrastructure requirements are needed to support that?

JOSLYN: Storage and bandwidth are a huge deal, especially as they relate to imaging. Every year, for example, we go up by an order of two the number of slices we need in a CT. At some point, maybe there's diminishing return.

STETTHEIMER: The disruptive things in terms of storage, computing power, and bandwidth are going to include things like digital pathology and genomics. As we really get into integration of imaging into core enterprise imaging repositories, those things become more disruptive to the path that we've been on in terms of the meaningful use requirements.

GIBBS: Even the digitization of the cath labs substantially increased the amount of bandwidth and storage that you need. When they start going to digital, you're talking 1 gig per study in terms of the raw storage.

MORLEY: Hospital executives are asking their IT departments to take the lead and deliver applications without really understanding the level of investment required to build a sustainable infrastructure. Clinical applications have to be supported with high performance computing, scalable storage, and broad bandwidth. Without those elements, applications will perform sluggishly or fail, frustrating caregivers and causing widespread adoption challenges. IT executives are caught between a rock and a hard place because they can't effectively deploy these strategies with the current budget structures or constraints.

STETTHEIMER: We have to be careful about leading the charge. What we try to avoid is the IT organization doing "the ask" for these technologies, particularly when it comes to big investments. We want to come in as a partner with the business owners. If it's the radiologist, nursing, we want our business owners to be pointing out the value proposition that's involved with these technologies.

MORLEY: A major responsibility of the IT team is to operationalize the strategy as defined by the core business constituents. IT executives should collaborate with the business owners to determine the path forward.

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