Health Informatics Integration: Pursuing This Holy Grail in … · 2009-10-02 · Health Informatics Integration: Pursuing This Holy Grail in Canada and Abroad Bruce A. Friedman,

Health Informatics Integration: Health Informatics Integration: Pursuing This Holy Grail in Canada Pursuing This Holy Grail in Canada

and Abroadand Abroad

Bruce A. Friedman, M.D.Bruce A. Friedman, M.D.Active Emeritus Professor of PathologyActive Emeritus Professor of PathologyUniversity of Michigan Medical SchoolUniversity of Michigan Medical School

Ann Arbor, MI 48109Ann Arbor, MI 48109President, Pathology Education ConsortiumPresident, Pathology Education Consortium

My email: My email: [email protected]@labinfotech.comMy blog: My blog: www.labsoftnews.comwww.labsoftnews.com

Twitter: @labinfotechTwitter: @labinfotech

mailto:[email protected]

http://www.labsoftnews.com/

Slide Slide 22

Lecture OutlineLecture Outline

Definition of Definition of integrationintegration as it relates to healthcare, dx, rx & as it relates to healthcare, dx, rx & wellness: attention to information systems & organizationswellness: attention to information systems & organizations

Specific examples of integration encountered in pathology, Specific examples of integration encountered in pathology, lab medicine, & information technology to be addressedlab medicine, & information technology to be addressed

The disease model, wellness, & healthcare reform; The disease model, wellness, & healthcare reform; criticality of diagnostics in modern healthcare deliverycriticality of diagnostics in modern healthcare delivery

CaseCase--byby--case discussion of different examples of case discussion of different examples of integration; consideration of the critical drivers of eachintegration; consideration of the critical drivers of each

Lecture wrapLecture wrap--up with attention to various critical integration up with attention to various critical integration pathways; some shaky prediction about the future of fieldpathways; some shaky prediction about the future of field

Slide Slide 33

Integration (e.g. IT, System, Organization, Integration (e.g. IT, System, Organization, Specialty): My Favorite TopicSpecialty): My Favorite Topic

No problem for me to lecture on topic of integration; have No problem for me to lecture on topic of integration; have spent most of my career trying to understand this termspent most of my career trying to understand this term

Reason why important is that most Reason why important is that most ““systemssystems”” initially are initially are launched as separate entities until value/merit is provenlaunched as separate entities until value/merit is proven

Subsequently, each of them need to be merged/integrated Subsequently, each of them need to be merged/integrated with related with related ““systemssystems”” to enhance coordination & efficiencyto enhance coordination & efficiency

Such integration often technically difficult; as they evolve, Such integration often technically difficult; as they evolve, systems may acquire its own unique goals, rules, budgetsystems may acquire its own unique goals, rules, budget

Also politically difficult; each system, as it is develops, has Also politically difficult; each system, as it is develops, has its own personnel roster who may resist change & reformits own personnel roster who may resist change & reform

Defining integration

Slide Slide 44

Value of Integration Mainly in the Value of Integration Mainly in the Eyes of the BeholderEyes of the Beholder

Value of integration frequently in the eyes of the beholder; Value of integration frequently in the eyes of the beholder; depends on whose work product/work flow benefits from itdepends on whose work product/work flow benefits from it

Benefits frequently flow from greater access to capital, Benefits frequently flow from greater access to capital, economies of scale, broader appeal to customers, etc.economies of scale, broader appeal to customers, etc.

From hierarchical/control perspective, often winners & From hierarchical/control perspective, often winners & losers; frequently loss of autonomy & training challengeslosers; frequently loss of autonomy & training challenges

Major drivers may be economic, quality, regulatory, Major drivers may be economic, quality, regulatory, technical, scientific; AP/CP integration as good exampletechnical, scientific; AP/CP integration as good example

Culture always trumps strategy; important to tease out & Culture always trumps strategy; important to tease out & examine cultural issues at play; often key in healthcareexamine cultural issues at play; often key in healthcare


Slide Slide 55

Setting the Stage for Integration Setting the Stage for Integration Discussion in Pathology & Lab MedicineDiscussion in Pathology & Lab Medicine

Period of unrest about healthcare delivery; expectation of Period of unrest about healthcare delivery; expectation of high quality services but less interest in paying for themhigh quality services but less interest in paying for them

Particularly in the U.S., interest in healthcare reform but Particularly in the U.S., interest in healthcare reform but difficult to define & achieve; vested interests lobby heavilydifficult to define & achieve; vested interests lobby heavily

Today will focus on two key elements in healthcare: (1) Today will focus on two key elements in healthcare: (1) clinical lab/pathology services; (2) information technologyclinical lab/pathology services; (2) information technology

Per title of lecture, will pay special attention to integration Per title of lecture, will pay special attention to integration as a means to achieve more efficient and effective careas a means to achieve more efficient and effective care

Recurrent theme will be growing criticality of diagnostics in Recurrent theme will be growing criticality of diagnostics in healthcare delivery; now entering golden era of this fieldhealthcare delivery; now entering golden era of this field


Slide Slide 66

Examples of Integration Pathology & IT Examples of Integration Pathology & IT Integration Under DiscussionIntegration Under Discussion

(1) Integration(1) Integration of Clinical Pathology with Anatomic Pathology; of Clinical Pathology with Anatomic Pathology; integration of upstream diagnostics with downstream therapeuticsintegration of upstream diagnostics with downstream therapeutics

(2) Workflow integration(2) Workflow integration of digital pathology with LIS, RIS and of digital pathology with LIS, RIS and PACS; introduction of the pathologist dashboard/consolePACS; introduction of the pathologist dashboard/console

(3)(3) IntegrationIntegration of Pathology, Lab Medicine, & Radiology to form new of Pathology, Lab Medicine, & Radiology to form new specialty of Diagnostic Medicine; Integrated Diagnostic Centersspecialty of Diagnostic Medicine; Integrated Diagnostic Centers

(4) Development of(4) Development of lab networkslab networks (hospital LIS + esoteric reference (hospital LIS + esoteric reference lab LISs); pursuit of lab LISs); pursuit of integratedintegrated clinical lab database for patient careclinical lab database for patient care

(5 Downstream integration(5 Downstream integration of the expanding LIS with the hospital of the expanding LIS with the hospital EMR; consideration of the technical & political challenges involEMR; consideration of the technical & political challenges involvedved

(6) Dis(6) Dis--integration of pathologyintegration of pathology, driven by reimbursement issues & , driven by reimbursement issues & upstream dx integrationupstream dx integration by clinical officeby clinical office--based specialty groupsbased specialty groups

Examples of integration

Slide Slide 77

Criticality of Diagnostics in Emerging Criticality of Diagnostics in Emerging Healthcare Delivery ModelHealthcare Delivery Model

Emergence of healthcare model with more emphasis on Emergence of healthcare model with more emphasis on diagnostics; highly significant for labs, pathology, radiologydiagnostics; highly significant for labs, pathology, radiology

Result of better technology & science; prominence of the field Result of better technology & science; prominence of the field will be enhanced by will be enhanced by integrated diagnosticsintegrated diagnostics (see later)(see later)

Also opportunity to reshape relationship of labs Also opportunity to reshape relationship of labs consumers; consumers; lab medicine begin to develop ongoing relationship with them lab medicine begin to develop ongoing relationship with them

Relationship to consumers will require greater familiarity with Relationship to consumers will require greater familiarity with Web 2.0; source of both information & link to consumersWeb 2.0; source of both information & link to consumers

Limitations/barriers will Limitations/barriers will notnot be erected by marketplace; be erected by marketplace; determined by ambitions/vision/skill set of lab professionalsdetermined by ambitions/vision/skill set of lab professionals

Disease model, wellness, reform

Slide Slide 88

State of Wellness (Absence of Diagnosable Disease)

State of Diagnosable Acute Disease(Short-Term, Self-Limiting)

State of Chronic Diagnosable Disease(Long Duration and/orFrequent Recurrence)

PreventiveMedicine,

Predictive Medicine,AlternativeMedicine

GenomicMedicine/

Predispositionto Disease

Wel

lnes

s D

omai

nO

vert

Dis

ease

Dom

ain

Early Health M

odel Dom

ain

Diagnostics pushing in

this direction

(See next for more details)


Slide Slide 99

Wellness vs. Overt Disease; Emergence Wellness vs. Overt Disease; Emergence of Preof Pre--Disease as Significant CategoryDisease as Significant CategoryIn previous diagram, major separation between wellness In previous diagram, major separation between wellness and overt disease; most MDs trained to diagnose latterand overt disease; most MDs trained to diagnose latter

Sophisticated diagnostic techniques uncovering genetic Sophisticated diagnostic techniques uncovering genetic predisposition to disease & prepredisposition to disease & pre--diseases in earliest formsdiseases in earliest forms

Because MDs & hospitals focus on overt disease, Because MDs & hospitals focus on overt disease, consumers tilting to consumers tilting to complementary/alternative medicinecomplementary/alternative medicine

In U.S., CAM accounts for 1/3 of outIn U.S., CAM accounts for 1/3 of out--ofof--pocket spending on pocket spending on prescription drugs & 1/4 of spending on healthcare visits.prescription drugs & 1/4 of spending on healthcare visits.

Lab professionals should place more emphasis on Lab professionals should place more emphasis on predictive/preventive medicine; capture more of this marketpredictive/preventive medicine; capture more of this market


Slide Slide 1010

Deloitte Healthcare

Pyramid as Basis for Healthcare Reform in the

U.S.


Healthcare ITas pyramid base

Note emphasison PHRs


Slide Slide 1111

Further Discussion about the Deloitte Further Discussion about the Deloitte Healthcare Reform PyramidHealthcare Reform Pyramid

Critical element in most healthcare reform proposals in U.S. Critical element in most healthcare reform proposals in U.S. is more support for IT; current emphasis on EMRs is more support for IT; current emphasis on EMRs

Much of current healthcare reform research focuses on Much of current healthcare reform research focuses on comparative effectiveness of treatment; related to EBMcomparative effectiveness of treatment; related to EBM

Reimbursement for episodesReimbursement for episodes--ofof--care as alternative to feecare as alternative to fee--forfor--service; lab testing will be key metric for assessing valueservice; lab testing will be key metric for assessing value

CoordinationCoordination--ofof--care poses challenge in the U.S.; burden care poses challenge in the U.S.; burden falls on primary care practitioners who are in short supplyfalls on primary care practitioners who are in short supply

Consumerism & PHRs at top of pyramid; opportunity to Consumerism & PHRs at top of pyramid; opportunity to engage consumers in their care if maintain PHR platformengage consumers in their care if maintain PHR platform


Slide Slide 1212

(1) Integration of Clinical Pathology & Clinical (1) Integration of Clinical Pathology & Clinical Pathology; Diagnostics with TherapeuticsPathology; Diagnostics with Therapeutics

Clinical pathology has long been diverging from surgical Clinical pathology has long been diverging from surgical pathology; now some early signs of convergence of twopathology; now some early signs of convergence of two

Surgical pathology moving beyond morphology and Surgical pathology moving beyond morphology and subjectivity to more scientific & quantitative approachsubjectivity to more scientific & quantitative approach

Major stimulus from new emphasis on quantitative & Major stimulus from new emphasis on quantitative & qualitative tissue/tumor biomarkers & algorithms (see next)qualitative tissue/tumor biomarkers & algorithms (see next)

This integration, as well as increased adoption of digital This integration, as well as increased adoption of digital pathology, a necessary precursor to integrated diagnosticspathology, a necessary precursor to integrated diagnostics

With integrated diagnostics, diagnostician uses various lab With integrated diagnostics, diagnostician uses various lab tests & imaging modalities to arrive at the correct diagnosistests & imaging modalities to arrive at the correct diagnosis

Different examples integration

Slide Slide 1313

Great progress in development of Great progress in development of ““companion algorithmscompanion algorithms”” for for automated scoring of digitized IHC & FISH tumor slidesautomated scoring of digitized IHC & FISH tumor slides

Theoretically, this approach can minimize interTheoretically, this approach can minimize inter--observer observer variation and subjectivity in interpretation of special stainsvariation and subjectivity in interpretation of special stains

Special billing code has been assigned to automated IHC Special billing code has been assigned to automated IHC interpretation, allowing improved ROI for capital investmentinterpretation, allowing improved ROI for capital investment

As noted previously, molecular dx & IVDMIAs moving toward As noted previously, molecular dx & IVDMIAs moving toward algorithmalgorithm--enabled CP diagnoses incorporated in reportsenabled CP diagnoses incorporated in reports

Possible that CP and AP will coalesce around basic concept Possible that CP and AP will coalesce around basic concept of computerized algorithms that convert data of computerized algorithms that convert data diagnosesdiagnoses

AlgorithmAlgorithm--Driven Diagnostics as Driven Diagnostics as Precursor to Precursor to ““BlendedBlended”” CP and APCP and AP


Slide Slide 1414

Broader Adoption of Digital Pathology: Broader Adoption of Digital Pathology: Precursor for Integrated DxPrecursor for Integrated Dx

Conversion to digital pathology will take longer than digital Conversion to digital pathology will take longer than digital radiology; wonradiology; won’’t result in higher margins/new procedurest result in higher margins/new procedures

Technology has also taken longer to mature; challenge of Technology has also taken longer to mature; challenge of whole slide imaging and huge file storage requirementswhole slide imaging and huge file storage requirements

Digital pathology will be prerequisite for deployment of Digital pathology will be prerequisite for deployment of integrated diagnostics given that radiology 100% convertedintegrated diagnostics given that radiology 100% converted

One One ““killer appkiller app”” for digital pathology will be for digital pathology will be ““image searchimage search””; ; compare areas of interest against reference databasescompare areas of interest against reference databases

Another important enabling technology is the pathology Another important enabling technology is the pathology cockpit or dashboard; whole slide images + all clinical datacockpit or dashboard; whole slide images + all clinical data


Slide Slide 1515

Possible Regulatory Oversight Over Possible Regulatory Oversight Over Serum AlgorithmsSerum Algorithms

The Food & Drug Administration (FDA) has recently shown The Food & Drug Administration (FDA) has recently shown interest in regulating the algorithms associated with IVDMIAsinterest in regulating the algorithms associated with IVDMIAs

Prompted, in part, by hesitancy of some diagnostics Prompted, in part, by hesitancy of some diagnostics companies to make public the details about their algorithmscompanies to make public the details about their algorithms

FDA also has concern about the research studies & serum FDA also has concern about the research studies & serum sample libraries used for clinical validation of some IVDMIAssample libraries used for clinical validation of some IVDMIAs

I am nervous about any regulatory oversight over clinical I am nervous about any regulatory oversight over clinical diagnostic algorithms; may inhibit progress in IVDMA fielddiagnostic algorithms; may inhibit progress in IVDMA field

FDA oversight over the blood banking modules of LISs FDA oversight over the blood banking modules of LISs caused a number of lab software companies to exit marketcaused a number of lab software companies to exit market


Slide Slide 1616

Extension of Diagnostics into Extension of Diagnostics into Therapeutic DecisionTherapeutic Decision--MakingMaking

One of my hopes is that companion diagnostics & IVDMIAs One of my hopes is that companion diagnostics & IVDMIAs will increasingly blend diagnosis with therapeutic decisionswill increasingly blend diagnosis with therapeutic decisions

This is the norm in cancer hospitals where multidisciplinary This is the norm in cancer hospitals where multidisciplinary teams collaborate in arriving at best therapeutic regimensteams collaborate in arriving at best therapeutic regimens

This concept is suggested in the term This concept is suggested in the term ““companion companion therapeuticstherapeutics””; notion that therapy may flow from dx workup; notion that therapy may flow from dx workup

Next diagram illustrates point; rx recommendations Next diagram illustrates point; rx recommendations generated at bottom following preceding dx steps generated at bottom following preceding dx steps

This may be a pipeThis may be a pipe--dream but not inconceivable that dream but not inconceivable that choice of chemotherapy regimens may be semichoice of chemotherapy regimens may be semi--automaticautomatic


Slide Slide 1717

Symptomatic or asymptomatic patient

Patient enters diagnostic & therapeutic effectiveness

process

Medical imaging

procedures

Molecular dx testing

Determination of variations in genes, gene expression, proteins, & metabolites, of patient, diseased tissue, and/or tumor; extent of lesion.

Lab methods to determine optimal drug therapy

Mandated lab companion testing to assess efficacy

Additional genomic/proteomictesting for efficacy and side-

effects

Appropriate drug therapy initiated

Diagnostic Work Flow Diagram Underlying Targeted Therapy


Slide Slide 1818

(2) Workflow Integration of Digital (2) Workflow Integration of Digital Pathology PACS With LIS and RISPathology PACS With LIS and RIS

With analog surgical pathology, no need for workflow With analog surgical pathology, no need for workflow integration; managed by APintegration; managed by AP--LIS separately from CPLIS separately from CP

Now surgical pathologists need to be aware of serum & Now surgical pathologists need to be aware of serum & tissue biomarkers; also need to review radiology findingstissue biomarkers; also need to review radiology findings

This integration component is being addressed by new This integration component is being addressed by new product offerings: frontproduct offerings: front--end pathology dashboard/consoleend pathology dashboard/console

LISs & RISs have 30LISs & RISs have 30--40 year history; optimal workflow 40 year history; optimal workflow assumptions preassumptions pre--baked into systems; no need to inventbaked into systems; no need to invent

Digital pathology systems less mature; most of effort Digital pathology systems less mature; most of effort focused on scanners, user interface, & interp. algorithmsfocused on scanners, user interface, & interp. algorithms


Slide Slide 1919

(3) Integration of Pathology, Lab Medicine & (3) Integration of Pathology, Lab Medicine & Radiology; New Specialty of Dx MedicineRadiology; New Specialty of Dx Medicine

I have been advocating the merger of pathology, lab I have been advocating the merger of pathology, lab medicine, & radiology in my blog since October, 2006medicine, & radiology in my blog since October, 2006

Several reasons for pursuit of this merger: related facets of Several reasons for pursuit of this merger: related facets of diagnostics, higher quality, growth of molecular imagingdiagnostics, higher quality, growth of molecular imaging

Radiology imaging has delivered Radiology imaging has delivered ““impressionsimpressions”” in past; in past; molecular imaging has potential to deliver firm diagnosesmolecular imaging has potential to deliver firm diagnoses

Anticipated quality improvements from opportunity to pull Anticipated quality improvements from opportunity to pull diagnosticians from their silos; benefits of crossdiagnosticians from their silos; benefits of cross--correlationcorrelation

Cost improvements relate to the potential for earlier Cost improvements relate to the potential for earlier diagnoses; less expensive to treat early malignant lesionsdiagnoses; less expensive to treat early malignant lesions


Slide Slide 2020

Integrated Diagnostic Centers (IDCs): Integrated Diagnostic Centers (IDCs): Tangible Proof of Value of Integrated DxTangible Proof of Value of Integrated Dx

Radiologists have developed Breast Centers over years Radiologists have developed Breast Centers over years with focus on screening mammography & dx of masseswith focus on screening mammography & dx of masses

Opportunity now for such centers to provide integrated Opportunity now for such centers to provide integrated reports (radiology + pathology) & more dx coordinationreports (radiology + pathology) & more dx coordination

Centers will spawn new software: merged LIS+RIS+ PACS; Centers will spawn new software: merged LIS+RIS+ PACS; also integrated pathologist/radiologist dashboardalso integrated pathologist/radiologist dashboard

Opportunity for workflow software that will manage & Opportunity for workflow software that will manage & facilitate handfacilitate hand--offs from pathology/labs to radiologyoffs from pathology/labs to radiology

IDCs offer hospital pathology opportunity to compete with IDCs offer hospital pathology opportunity to compete with national reference labs; cannational reference labs; can’’t offer similar dx services t offer similar dx services


Slide Slide 2121

Defining and Understanding the Value of Defining and Understanding the Value of the Integrated Diagnostic Center (IDC)the Integrated Diagnostic Center (IDC)

An IDC is a clinic with the mission of diagnosing An IDC is a clinic with the mission of diagnosing patients with lesions using multidisciplinary team patients with lesions using multidisciplinary team

MDTs consist of clinicians, pathologists, & radiologists MDTs consist of clinicians, pathologists, & radiologists who collaborate to quickly diagnose referred patientswho collaborate to quickly diagnose referred patients

MDTs have many advantages: intraMDTs have many advantages: intra--team team communication, referrals, & handcommunication, referrals, & hand--offs are facilitatedoffs are facilitated

In the UK, Patients with breast masses are referred to In the UK, Patients with breast masses are referred to IDCs which are called IDCs which are called ““oneone--stopstop”” breast clinicsbreast clinics

No reason why IDCs cannot also be used to dx No reason why IDCs cannot also be used to dx diseases other than breast such as lung, GU, & GIdiseases other than breast such as lung, GU, & GI


Slide Slide 2222

How Are Breast Masses How Are Breast Masses CurrentlyCurrentlyDiagnosed in a Community Setting?Diagnosed in a Community Setting?Breast masses identified by PCP, surgeon, or internist, Breast masses identified by PCP, surgeon, or internist, who then assumes responsibility for the dx processwho then assumes responsibility for the dx process

Requires coordinating multiple appointments with Requires coordinating multiple appointments with radiology & pathology; interpretation of multiple reportsradiology & pathology; interpretation of multiple reports

Within an IDC, unit assumes coordination & integration Within an IDC, unit assumes coordination & integration responsibility; also generates integrated reportresponsibility; also generates integrated report

Initially, IDC processes are integrated by team Initially, IDC processes are integrated by team collaboration & proximity, quickly reducing complexitycollaboration & proximity, quickly reducing complexity

In time, IDCs will develop automated workflow In time, IDCs will develop automated workflow algorithms that will further increase unit efficiencyalgorithms that will further increase unit efficiency


Slide Slide 2323

Basis for Claim that IDCs are Faster, Basis for Claim that IDCs are Faster, Better, and Less ExpensiveBetter, and Less Expensive

FasterFaster: result of MDT, enabling integrated & efficient : result of MDT, enabling integrated & efficient communication, & scheduling of work processes communication, & scheduling of work processes

BetterBetter (i.e., higher quality): mistakes in healthcare (i.e., higher quality): mistakes in healthcare can result from errors in communication & handcan result from errors in communication & hand--offsoffs

Less expensiveLess expensive: result of integrated administrative : result of integrated administrative processes within IDCs such as reporting/scheduling processes within IDCs such as reporting/scheduling

Faster, better, & less expensive together will be Faster, better, & less expensive together will be perceived by patients as superior in marketplaceperceived by patients as superior in marketplace

In terms of patient satisfaction, compare a final dx for In terms of patient satisfaction, compare a final dx for a lesion in days compared to current performancea lesion in days compared to current performance


Slide Slide 2424

(4) Integration Of Lab Data With Reference (4) Integration Of Lab Data With Reference Lab Data to Form Laboratory NetworkLab Data to Form Laboratory Network

Many small to medium size hospital labs will be challenged Many small to medium size hospital labs will be challenged by need to offer wide array of genomic/proteomic testing by need to offer wide array of genomic/proteomic testing

Easy solution that has been partly attempted in past: Easy solution that has been partly attempted in past: tighter operational/software integration with esoteric labstighter operational/software integration with esoteric labs

Concept of Concept of lab networklab network goes far beyond mere interfaces goes far beyond mere interfaces between LISs; taskbetween LISs; task--sharing with frontsharing with front--end specimen prepend specimen prep

With national (or international) lab network in place, opens With national (or international) lab network in place, opens door for competitive bidding across reference labs for workdoor for competitive bidding across reference labs for work

Hospital labs opt for closer Hospital labs opt for closer ““upstreamupstream”” integration with lab integration with lab network than network than ““downstreamdownstream”” integration with hospital EMRsintegration with hospital EMRs


Slide Slide 2525

Some of the Consequences of Emerging Some of the Consequences of Emerging Diagnostic NetworksDiagnostic Networks

Concept of a diagnostic network pioneered by Nighthawk Concept of a diagnostic network pioneered by Nighthawk Radiology; offRadiology; off--hours interpretation of images in the U.S.hours interpretation of images in the U.S.

Concept now morphing into Concept now morphing into ““dayhawkdayhawk””; services being offered ; services being offered during daylight hours; local radiology groups losing contractsduring daylight hours; local radiology groups losing contracts

New companies like Telerays offer competitive bidding by New companies like Telerays offer competitive bidding by hospitals for radiologist services; network opens markethospitals for radiologist services; network opens market

Hospital labs have had LIS interfaces to esoteric reference Hospital labs have had LIS interfaces to esoteric reference labs for many years; more efficient lab test ordering/reportinglabs for many years; more efficient lab test ordering/reporting

Lab networks can cut two ways; empowerment of small Lab networks can cut two ways; empowerment of small hospital labs or remote support for surgical pathology workhospital labs or remote support for surgical pathology work


Slide Slide 2626

Pathology and Lab Medicine

Radiology

Hospital LIS

Esoteric Reference

Lab

Hospital RIS/PACS

Reference Lab LIS

Nighthawk Radiology

Nighthawk RIS/PACS

IntegratedDiagnostic

Center (IDC)

Diagnostic Information

System (DIS)

Esoteric Reference

Lab Network

Reference Lab LIS

Nighthawk RadiologyNetwork

Nighthawk RIS/PACS

IntegratedDiagnostic

Center (IDC)

Diagnostic Information

System (DIS)

Possible Evolutionary Sequence for IDCs, Possible Evolutionary Sequence for IDCs, DISs, and Diagnostic Lab NetworkDISs, and Diagnostic Lab Network

Super National “Diagnostics”

Network



Slide Slide 2727

Setting the Stage: The Wacky World of Setting the Stage: The Wacky World of Hospital EMRsHospital EMRs

Attention in U.S. focused on proven lack of success of many Attention in U.S. focused on proven lack of success of many hospital EMRs; assumption that funding will solve problemhospital EMRs; assumption that funding will solve problem

In contrast, LISs, RISs, PACSs have long history of success; In contrast, LISs, RISs, PACSs have long history of success; selected by professionals who use them daily for productivityselected by professionals who use them daily for productivity

EMR problem relates more to following: systems expensive & EMR problem relates more to following: systems expensive & outdated; shift greater work to MDs; difficult to maintainoutdated; shift greater work to MDs; difficult to maintain

EMRs largely unable to store & display complex molecular EMRs largely unable to store & display complex molecular data & images generated in both pathology & radiologydata & images generated in both pathology & radiology

Tethered, webTethered, web--based PHRs like HealthVault emerging; MS based PHRs like HealthVault emerging; MS creating strategic hospital alliances; will consumers adopt?creating strategic hospital alliances; will consumers adopt?


Slide Slide 2828

(5) Integration of LIS with Hospital EMRs; (5) Integration of LIS with Hospital EMRs; Technical & Political ChallengesTechnical & Political Challenges

One aspect of integration demanded of LISs is that they One aspect of integration demanded of LISs is that they replicate test results to the hospital EMR for MD efficiencyreplicate test results to the hospital EMR for MD efficiency

Politically inexpedient to describe this as difficult after Politically inexpedient to describe this as difficult after hospital CEOs have spent millions of $$ on their EMRshospital CEOs have spent millions of $$ on their EMRs

Only acceptable strategy is to replicate only topOnly acceptable strategy is to replicate only top--level level impressions/dximpressions/dx’’s for genomic/proteomic tests to EMRs for genomic/proteomic tests to EMR

For detailed test results, clinicians will need to be linked to For detailed test results, clinicians will need to be linked to the LIS; solidifies future role of LIS & backthe LIS; solidifies future role of LIS & back--end lab networkend lab network

This problem intensified as EMR vendors take more control This problem intensified as EMR vendors take more control over installs; Epic/Meditech allow few changes to systemsover installs; Epic/Meditech allow few changes to systems


Slide Slide 2929

Federated Model as Best Architecture Federated Model as Best Architecture for Future Hospital EMRsfor Future Hospital EMRs

Makes no sense to deconstruct lab formatting with HLMakes no sense to deconstruct lab formatting with HL--7 7 interface from LIS to EMR; need to reformat on EMR sideinterface from LIS to EMR; need to reformat on EMR side

““FederatedFederated”” architecture superior; LIS and RIS become architecture superior; LIS and RIS become peers to EMR; peers to EMR; ““white spacewhite space”” in EMR is in EMR is ““rentedrented”” to themto them

Clinician queries to the EMR for ancillary data are then Clinician queries to the EMR for ancillary data are then fulfilled on the fly; formatting of lab results remain in the lafulfilled on the fly; formatting of lab results remain in the labb

Unlikely that this architecture will be adopted; EMR Unlikely that this architecture will be adopted; EMR vendors only willing to make marginal changes to systemsvendors only willing to make marginal changes to systems

Ancillary data key components of the EMR database; canAncillary data key components of the EMR database; can’’t t justify current EMR cost structure selling justify current EMR cost structure selling ““white spacewhite space””


Slide Slide 3030

(6) Integration of Surgical Pathology into (6) Integration of Surgical Pathology into Practices; Example of Vertical IntegrationPractices; Example of Vertical IntegrationAnother form of service integration now occurring with Another form of service integration now occurring with large specialty practices (GI,GU) creating inlarge specialty practices (GI,GU) creating in--office labsoffice labs

These histology labs process tissue biopsy specimens that These histology labs process tissue biopsy specimens that are then interpreted by pathologist(s) working for the groupare then interpreted by pathologist(s) working for the group

More revenue generated for the clinical group because More revenue generated for the clinical group because both the technical & professional fees accrue to the groupboth the technical & professional fees accrue to the group

Pathologists frequently not partners in practice groups but Pathologists frequently not partners in practice groups but contractors to them; much less job security in positions contractors to them; much less job security in positions

Despite tenuous positions, these pathologists often happy Despite tenuous positions, these pathologists often happy because they have been trained in subspecialty work because they have been trained in subspecialty work


Slide Slide 3131

Fragmentation of Pathology; What Will Fragmentation of Pathology; What Will the Future Hold for the Specialty?the Future Hold for the Specialty?

Except in academic centers, pathologists have largely Except in academic centers, pathologists have largely exited from clinical labs; emphasis on surgical pathologyexited from clinical labs; emphasis on surgical pathology

Irony is this departure from clinical labs at a time when Irony is this departure from clinical labs at a time when serum & tissue biomarkers becoming more essentialserum & tissue biomarkers becoming more essential

Small biopsy work (see previous) being taken over by Small biopsy work (see previous) being taken over by clinical groups because generates additional revenueclinical groups because generates additional revenue

Much of diagnostic/corrective surgery becoming minimally Much of diagnostic/corrective surgery becoming minimally invasive; migrating to ambulatory, office, & ASC settingsinvasive; migrating to ambulatory, office, & ASC settings

Solution involves young physicians entering pathology will Solution involves young physicians entering pathology will high interest in genomics/proteomics; will revitalize fieldhigh interest in genomics/proteomics; will revitalize field


Slide Slide 3232

Summary: Weaving All of These Views Summary: Weaving All of These Views of Integration into View of Futureof Integration into View of Future

Need for quality/efficiency gains & new technology driving Need for quality/efficiency gains & new technology driving new integration agenda for pathology & lab medicinenew integration agenda for pathology & lab medicine

Common theme throughout this discussion has been need Common theme throughout this discussion has been need for more automation in healthcare delivery processfor more automation in healthcare delivery process

Diagnostics growing more sophisticated; opportunity for Diagnostics growing more sophisticated; opportunity for ““companion therapeuticscompanion therapeutics”” with automated rx selectionwith automated rx selection

Information technology represents a common Information technology represents a common ““enablingenabling””theme throughout all of these integration scenariostheme throughout all of these integration scenarios

Need to embrace integration opportunities when can result Need to embrace integration opportunities when can result in faster, better, less expensive dx services in healthcarein faster, better, less expensive dx services in healthcare

Lecture wrap-up

Documents

Health Informatics Integration: Pursuing This Holy Grail in … · 2009-10-02 · Health Informatics Integration: Pursuing This Holy Grail in Canada and Abroad Bruce A. Friedman,