Enabling emr ehr – best practices in integration

Enabling Enabling EMR/EHREMR/EHR –– Best Practices in Best Practices in IntegrationIntegrationWebinar, February 14, 2008Marc Holland, Program Director, Healthcare Provider ITSponsored by WIPRO Technologies and Sun Microsystems

© Health Industry Insights, an IDC company Page 2

Agenda

� U.S. Healthcare IT mega-trends

� EMRs vs. EHRs: similar but not the same

� The HIT Maturity Model: a framework for assessing progress

� So where are we now?

� So what’s HOTHOT in HIT?

� System Integration: the tie that binds

� Essential Guidance

� Sun Microsystems and WIPRO speakers

� Combined Q & A


US Healthcare IT Mega TrendsUS Healthcare IT Mega Trends


Healthcare IT: Poised for Growth� Healthcare costs are growing

– Medical technology, particularly in the US, is state of the art

– Population growth and longevity are taxing the system

� Healthcare has historically lagged other industries in using information technology

– That is changing, dramatically –and worldwide

� Healthcare IT seen as a tool to reduce healthcare costs and improve quality and safety

� CAGR for healthcare providers in the US > 6%

� CAGR for healthcare providers worldwide ~ 7%

– The tortoise and the hare?– US Hospital Provider IT annual

budget growth now roughly 10%


U.S. Provider Spend

Source: HII Worldwide Healthcare IT Spending Guide, 2006

0

5,000

10,000

15,000

20,000

25,000

30,000

2006 2007 2008 2009 2010

(%)

(M)

Hardware

Software

IT Services

01

234

567

89

%

About 85% of the total is About 85% of the total is spent by hospitalsspent by hospitals


Mega Trends: Industry Environment

� Focus on cost containment, quality of care and patient safety across the health ecosystem.

� Aging infrastructure, new technologies, and regulatory pressures are fueling a significant upgrade cycle.

� Innovation is essential but it is currently under funded.

� Analytics allow new insights into improving the quality and cost of care; essential for compliance (P4P, CMS Core Measures, personalized medicine, performance management, etc).

� Increased focus on collaborative IT investment. New tension andcompetition emerges for the investment funding between internal/legacy and external/collaborative business relationships, processes and investments.

� The lines between the life sciences, provider and payer sectors are continuing to blur as each sector is driven to improve quality and patient safety, and reduce healthcare costs.


Mega Trends: Industry Environment

� Focus on cost containment, quality of care and patient safety across the health ecosystem.

� Aging infrastructure, new technologies, and regulatory pressures are fueling a significant upgrade cycle.

� Innovation is essential but it is currently under funded.

� Analytics allow new insights into improving the quality and cost of care; essential for compliance (P4P, CMS Core Measures, personalized medicine, performance management, etc).

� Increased focus on collaborative IT investment. New tension andcompetition emerges for the investment funding between internal/legacy and external/collaborative business relationships, processes and investments.

� The lines between the life sciences, provider and payer sectors are continuing to blur as each sector is driven to improve quality and patient safety, and reduce healthcare costs.

= Increased automation, data collection = Increased automation, data collection and integration across the ecosystemand integration across the ecosystem


Healthcare is rapidly becoming an inter-connected ecosystem, with IT as its circulatory system

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� Offering EHR/EMR technology and PBHRs to provider constituents

� Balancing internal projects vs. external collaborative projects such as RHIO and HIE initiatives

� Providing revenue cycle mgt tools� Reimbursing for outcomes (P4P)� Reimbursing for remote home health

monitoring

� Identifying patients for clinical trials

� Utilizing EMRs to supplement electronic data capture (EDC) systems

� Exploring pharmacogenomics

� Identifying research sites and populations

� Drug safety and tracking

� Enabling consumers to get involved in managing their health

� Understanding increasing patient liability

� Improving quality of care (and of life) through remote home health monitoring ��

� Information connectivity� Translational medicine� Reducing costs and

improving patient outcomes


HIT Maturity Model:HIT Maturity Model:A Framework for Assessing ProgressA Framework for Assessing Progress


IDC-HII Hospital IT Maturity Model

Stage 1Basic HIS

• Patient Registration / Inpatient Admission Discharge & Transfer

• Patient Billing and Accounts Receivable

• HRIS / Payroll• General Ledger /

Financial Reporting• Purchasing /

Accounts Payable

Stage 2Advanced HIS

• Electronic Claims Submission (Discharge Summaries, Coding and Abstracting)

• Electronic Payment Processing

• Inventory, Supply Requisitioning and Distribution

• Basic Order Communications

• Email• Internet Access• Intranet

Stage 3Advanced HIS Core Clinicals

• Laboratory Information System

• RIS/Radiology Results Reporting

• PACS• Pharmacy• Operating Room

Scheduling and Management

Stage 4Digital

Hospital

• Patient Appointment Scheduling

• Computerized Physician Order Entry

• Nursing Documentation

• Emergency Department Management

• Physician Portal• Patient Portal• Wireless

Infrastructure

• Inpatient Electronic Medical Record (EMR)

• Ambulatory EMR

• Enterprise Master Patient Index

• Location-based services

Stage 5Digital Virtual

Enterprise

• Secure messaging (Provider-Provider/ Provider-Patient)

• Clinical Data Repository/ Data Warehouse

• Participation in Regionalized Patient CDR

• Home Health Case Management

• Remote Patient Monitoring/ Telemedicine

The key prerequisites The key prerequisites for an for an EMREMR


EMREMR vs. vs. EHREHR::Coming to TermsComing to Terms

Similar, but Not the SameSimilar, but Not the Same


Electronic Medical Records Defined

Clinical Data

Repository(CDR)

Clinical Decision Support

Workflow

Orders Results

Documentation

Controlled Medical Vocabulary

Enterprise Master Patient Index

Laboratory

Transcription

Electronic Data

Digitized Images

Patient: Jane Doe

General Hospital

Physician

X-ray

Nursing

Pharmacy

Admitting

Surgery

Emergency

Source: Health Industry Insights


Electronic Health Records Defined

Hospitals

Summarized Health Information

Electronic Medical

Recordsfor patient Jane Doe

Electronic Health Record� Table of contents/indexing� Viewer � Key diagnoses and procedures summaries � Labs and results� Medication history� Analytics, search & reporting tools� Security

$ Payer data

Patient provided data

Prescription data

Primary Care Providers Specialists Other Providers

Source: Health Industry Insights


HIT Maturity:HIT Maturity:So where are we now?So where are we now?


Hospital Adoption of EMRs is Increasing

� Only 23% of hospitals over 500 beds reported a “fully” operational EMRs based on an objective, 15-function point scale

� Only 13% of hospitals between 100 – 200 beds were “fully” implemented – 21% had no clinical IT deployed

� Only 7% of hospitals between 50 – 100 beds were “fully” implemented – 37% had no clinical IT deployed at all

� Urban higher than rural; teaching higher than non-teaching;

� But the trend is clearly favorable

0102030405060708090

100

<50 50-99 100-299 300-499 >500

(Bed Size)

(%)

Full (12 – 15 functions)

Partial (1 - 11)

Source: AHA 2nd Annual HIT Survey 2007

Vendor Market Notes• Fragmentation by solution set, geography and market segment.• Major hospital information system vendors dominate the EMR market.• CCHIT begins certifying inpatient EMRs, 9 certified between Nov. 2007 and Jan. 2008.• Market players: Cerner, CPSI, Dairyland, Eclipsys, Epic, GE Healthcare,

McKesson, MEDITECH, Siemens, QuadraMed


Physician Adoption of EMR is Increasing

� Overall, nearly 30% of physicians use an EMR system [comprehensive (14.5%) and partial (14.7%)] in their office-based practices.

� This represents a 22% increase since 2005 and a 60% increase since 2001.

� Adoption will continue. In 2006, 23.9% of office-based physicians surveyed reported that they planned to install a new EMR systems or replace their current systems within the next 3 years.

05

101520253035404550

Solo Partner 3 - 5 MDs 6 - 10 MDs 11 or moreMDs

(%)

Any EMRComprehensive EMR System

Source: CDC/NCHS, National Ambulatory Medical Care Survey, 2006 – published October 2007.

Vendor Market Notes• Continues to be a fragmented market. The market is wide open, and will remain so.• Approximately 100 ambulatory EMR products have been certified by CCHIT.• Buying “cooperatives” are emerging, sponsored by payers and local medical associations.• Web-based hosting services and SaaS gaining traction in the market place.• Major Market players: Allscripts, eClinicalWorks, GE (IDX), McKesson

(Practice Partner), Misys, NextGen, Sage (Emdeon/Med Mgr)


A Landmark 2004 Study Showed EMR Adoption in US Lagged Badly and Times Haven’t Changed Dramatically – EMEA is Far Ahead

Source: "European Physicians Lead U.S. in Use of Electronic Medical Records." Harris Interactive Health Care News 2(16). Reproduced from a presentation by Dr. David Bates, Mass General Hospital to the ACMI, 2004

EMR Rates of Adoption by Country (2002)

0102030405060708090

100

Sweden

Nether

lands

Denmar

k UKFin

land

Austria

Germ

any

Belgiu

m

Luxem

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land

Greece US

Spain

France

Portugal

Country

% M

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ract

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pera

tion

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MR

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Adoption %


Provider Initiatives Involving EHRs��

0 5 10 15 20 25 30 35 40

No, but active discussion to participate in a proprietary RHIO or HIE

Community-based RHIO; Info exchange operational

Proprietary RHIO; Info exchange operational

Proprietary RHIO; Info exchange planned

Community-based RHIO; Info exchange planned

No, and no plans to participate in any form of RHIO/HIE

No, but active discussion to participate in a community-based RHIO/HIE

N = 34Source: Health Industry Insights, Sept 2007

Vendor Market Notes

� Most are SOA-portal type architectures.

� Not all vendors offer a complete solution; but not all RHIOs want (or can afford) one.

� The market is wide open, but will likely bifurcate along public and private lines. It will also remain risky ….

� Market players: InterSystems (HealthShare), Oracle, Wellogic, Misys, Cerner, dbMotion, Quovadx, Carefx, Initiate Systems, Medicity, MEDSEEK, IBM, Orion Health Systems, Open Source Vendors (BrowserSoft and Tolven Health), Sun

� Operational health information exchange is not widespread. Less than 3% of respondents belong to a community-based RHIO and actively exchange health information. And only 8.8% of respondents are exchanging health information among related entities.

� More are in the planning phase; 17.7% participate in a community-based RHIO and 8.8% in a proprietary RHIO in the planning stages. Approximately 35% are in discussions to participate in a community-based RHIO.


Payer Initiatives Involving EHRs

0 10 20 30 40 50

Provider electronichealth record

systems

Provider electronicmedical record

systems

Consumerpersonal health

records

(%)

N = 62

Source: IDC Health Industry Insights Survey, 2007

� 43% of healthcare payers report planned investment in PHRs in 2008.

� EHRs (58.1) and PHRs (50.0) were among the top three external transparency initiatives driving business intelligence investment through 2010.

� In an informal study of health plan CMOs, 66% of respondents that deploying a PBHR was important or very important.

Consumerism (69.4%) and provider demands (37.1%) were the top two drivers for payer investment in collaborative healthcare initiatives. Interestingly, compliance with federal government mandates or regulations was less frequently cited (27.4%).

Vendor Market Notes• Attributes: Multiple models, no clear winners.• Challenges: Integration, adoption, information exchange• Major Market players: Active Health Management, Availity, HealthTrio, RelayHealth,

MEDecision, Medem, TriZetto, WebMD


WhatWhat’’s s HOTHOT in HIT?:in HIT?:Market Shaping Technologies for 2008Market Shaping Technologies for 2008


So What’s “Hot” in U.S. HIT?� EMRs, EHRs

– CPOE – Health Information Networks– The emergence of EMR Gen 2

� Business and clinical intelligence– Performance analysis– Evidence-based medicine– Personalized health

� Wireless– Wireless point of care devices (Gen 2)– Location-based services (RFID, Ultrasonic)

� Virtualization of servers, storage and desktops

� SOA, Integration platforms & portals

� Web 2.0

� SaaS

� Security

� Disaster Recovery /Biz Continuity


So What’s “Hot” in U.S. HIT?� EMRs, EHRs

– CPOE – Health Information Networks– The emergence of EMR Gen 2

� Business and clinical intelligence– Performance analysis– Evidence-based medicine– Personalized health

� Wireless– Wireless point of care devices (Gen 2)– Location-based services (RFID, Ultrasonic)

� Virtualization of servers, storage and desktops

� SOA, Integration platforms & portals

� Web 2.0

� SaaS

� Security

� Disaster Recovery /Biz Continuity

Systems integration technology is a critical element for unleashing the potential in most of these.


Systems Integration:Systems Integration:The Tie That BindsThe Tie That Binds


CIS Platforms: The Myth of the Single Source

Which of the following clinical information system (CIS) platform philosophies best describes your organization's current and future architectural approach?

Best-of-breed (20.6%)

Hybrid (52.9%)

Single suite (26.5%)

n=34

Best-of-breed (5.9%)

Hybrid (55.9%)

Single suite (38.2%)

n=34

Source: Health Industry Insights, 2007

Current Future


Data Integration in HIT: an Old but New Concept� HL7 introduced more than 20 yrs ago;

pioneered by Libra Health Technologies

� The HL7 organization (www.HL7.org) has become one of the most influential forces in the area of HIT standards definition and adoption

� But integration remains a complex issue as information sharing requirements increase in their diversity and complexity

� Different forms of integration requirements exist at different levels of business processes--

– Transaction – Document– Application – Enterprise– Platform

� Integration remains a major growth market


Data Integration: It’s Not Just About Messaging Systems Anymore� No longer a technology for just big hospitals

� No longer just HL7, but all of its variants and complementary technologies

– HL7 2.5, 3.0 (transaction format & data stds)– CDA and CCR (“translucent” attachments)– XML (web-page integration)– CCOW (application synchronization)

� Eight vendors now dominate the market for integration messaging platforms

– Eclipsys, InterSystems, Oracle, Orion, Quovadx, Siemens, Sun Microsystems, Sybase

� But also consider the need for products that provide integration at the context level, as well as single sign-on

– Carefx, Encentuate, Novell, Sentillion

� Think “virtually”; the “virtual healthcare enterprise” will drive demand for integration across all market segments


Selecting an Integration Platform: What to Look For

� Ease of implementation

� Technology

� Ease of development across all types of interfaces

� Upward migration

� Performance

� Backup and recovery

� Audit, monitoring, error mgt and security

� Service and support

� Application experience

� Testing and development

� Documentation

� Total cost of ownership


Essential Guidance

�� An EMR is a journey, not a An EMR is a journey, not a destinationdestination

� Make a clear business case

� Learn from the leaders

� Partner with your vendors

� It’s less about technology than it is about process

� Partner with your clinical leadership; you cannot succeed without their commitment

� Your competitors are also your colleagues – we all have the same goals in common – a healthier populace and improved access to quality care at affordable cost

� Ask questions, lots of questions; share your experiences


Questions

Marc HollandProgram DirectorHealthcare Provider IT Research

Please feel free to email me [email protected]


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Sun and Healthcare

Nancy Abell, RNSun Global Software Healthcare

February 14, 2008

Solutions to Bridge the Digital Divide


The Vision

Everyone and Everything Participating on the Network


Sun’s Solution

• Product: JavaTM

Composite Application Platform Suite – the industry’s most complete, unified and secure platform for SOA and composite applications

• Services: Life-cycle professional servicesand learning curriculumto augment yourin-house skills


AccessManager

ServicesRegistry(RegrepUDDI)

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Reusable Services

HIS

EMPILabInquiry RAD

CDR

RLS

Enterprise Network

OrdersResults

EnterprisePatientView

ExecutiveDashboards

IncreasedAgility

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Scheduling RAD / LAB

CompositeApplications

Pharm

Sun Java™ Composite Application Platform Suite

Composite Applications via Service-Oriented Architecture

Presentation Services

John Doe

TranscriptionRegistration EMPIImagingRadiology Pharmacy Laboratory


Sun JAVA™ Composite Application Platform Suite (CAPS)

eViewStudio

eBAMStudio

eVisionStudio

Sun Portal Server PE

View Generation

Composite Applications

eInsight Business Process ManagerOrchestration

eWayAdapters

eXchangeIntegrator

eXpressway

IntegratoreTL

Integrator

Repository

eGate Integrator

Enterprise M

anager

Enterprise D

esigner

Integration

Sun Directory Server

Sun Application Server

Sun Access Manager

Core Services

Sun Java StudioSun Java Creator

eIndex / eView Studio provides Patient information / Record

Locator Svs, cleansing, probabilistic matching, indexing,

and linking

eGate unlocks and exposes the data in your

existing applications

eInsight BPM also provides a rules engine to ensure security, and privileges are adhered

too

eInsight BPM orchestrates steps

necessary to satisfy generate Patient View

Executive / OperationsDashboards

Custom Patient Views

eWay adapters provide connection points between systems

eXchange automates B2B interactions


Solutions

…combining all integration technologies in one easy-to-use environment.

Built on a foundation of integration with unified capabilities for SOA, BPM, BAM, Single Entity View”…


Use Case: UK National Health Service • 50+ million patients with life-long healthcare records

• Linking with 250 hospitals

• 1.4m providers (doctors, nurses, scientists)

• 10,000 systems

• 40,000 sites

• For the National Service Provider (NASP) “Spine”> 2005 – 2 billion transactions per year> 2010 - 6 billion transactions per year> Due to peak usage approximately 420 messages per second

(4–6x hourly average)> Response SLA – 0.2 seconds> Available 99.9% (44 minutes per month downtime)> Failover in 30 minutes

• For the Local Service Providers (LSP’s)> Each has a lot of local messages (10bn to 12bn per year) and shares some

with the NASP

• There are 5 LSP and therefore the total volumes of messages per year is:> 56 billion to 66 billion messages per year

• Initially using eGate, eInsight, eView and eXchange

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Enterprise Master Patient Index – Active Mode

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Solution: Provide unique patient indexing across systems. Replace all patient search and registration functionality on top of existing applications via overlays and screen scraping. Eliminate duplicate patient records.

Use Case: Multi-hospital health system has dozens of systems and requires a single patient identifier.

In order to prevent future duplicates, eIndex with Active Integrationgenerates popup windows that overlays existing applications.

EMPI Validates whether or not patient exists before trying to add as a new record.


Colorado RHIO

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Solution: Portal that integrates to sites via web services and interfaces.Leverages existing systems instead of rip and replace. eIndex, RLS and IDM

Use Case: State initiative to link multiple data sources to a single portal for view by any authorized providers. Data must be retained in its original location but be available for view in an aggregated manner for providers---data such as lab results, radiology exam results, medications, problems, allergies and immunizations.

Use Case Phase 2: State initiative to apply patient data to accepted Clinical Guidelines/Protocols for feedback to treating physician.


Cleveland Clinic

Challenge • Eliminate errors in filling handwritten prescriptions

• Enable e-prescription functionality between clinic and pharmacies

• Increase patient satisfaction

• Using Sun integration software, the medical center was able to synch up communications between its internal prescription system and those existing at retail pharmacies

• Enabled communications between clinic and pharmacies systems

• Ensured accurate filling of e-prescriptions• Enhanced patient safety and care

Solution

Benefits


Sun – Your eHealth Partner• Interoperability through 16+ year history in HIT• Indexing through a proven master patient index• Commitment to ongoing standards development

through presence on HL7 committees• Sun Java Composite Application Platform Suite

enables all integration initiatives


Sun’s 360°Health Info Exchange Architecture

AcademicMedical Center

PublicHealth

SpecialtyClinic

Hospital

ReferenceLaboratory

MedicalSupplier

Long-TermCare

DiagnosticImaging Center

Finance Researchand Education

EmergencyServices

Physicians

Home Health

PrivateInsurance

GovernmentInsurance

Pharmacy BenefitManagement

Employer

Single-Patient View

Ambulatory Centers

Payers

Pharmacy

ClinicalDocuments

ScreeningRegisters


The Sun Prescription

• An interoperable and highly extensible healthcare solution

• Solutions and infrastructure to transform the way healthcare records, tracks, and accesses critical business information

• Sun is the remedy for healthcare information exchange initiatives that need to find a more cost-effective way to standardize and exchange critical information between their entities.

Enabling EMR/EHR – Best Practices in Integration

Wipro Technologies

© 2007, Wipro Technologies

Healthcare Provider Organization Context

• Between 44,000 and 98,000 Americans die each year from medical errors. • Many more die or have permanent disability because of inappropriate treatments,

mistreatments, or missed treatments in ambulatory settings. • $300 billion is spent each year on healthcare does not improve patient outcomes –

treatment that is unnecessary, inappropriate, inefficient, or ineffective.• Patients with medical emergencies too often are seen by doctors with no access to

their critical medical information, such as allergies, current treatments or medications, and prior diagnoses

Source: Institute of Medicine

Well Designed Application Integration with Industry Standard tools and Services can help to reduce some of these instances

• Prescribing Error Rates and Quality Issues– More than 3B prescriptions are written per year (AHRQ)– Pharmacists make 150M calls to physicians each year to discuss possible errors or

clarify prescriptions (ISMP) – 8.8M ADE’s occur each year in ambulatory care, of which more than 3M are

preventable (CITL)– Medication errors account for 1 out of 131 ambulatory care deaths (CITL)


Integration Best Practices Help the Achieve Objectives

Improved Quality of Care and Patient Satisfaction

Greater ROI

Seamless Integration

Enhanced Risk Management

Increased Efficiency


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Tools, Services and Methodology is the Key for Success

• Sun Microsystems

• Quovadx

• InterSystems

• Oracle

• Orion

• Eclipsys

• Siemens

• Sybase


Facts & Figures• Largest Integration Practice in APAC• Largest Pool of HL7 Certified Professionals having 10+

years of collective experience in healthcare interface• Extensive Product Expertise • Extensive functional expertise in many vertical domains

such as healthcare, manufacturing, retail, automotive, energy and utilities

• Well established global delivery model• Innovative Engagement Models • Large Investments In Dedicated Center of Excellence

(CoE)

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Accelerators from Wipro Services

OutcomeIntegration Challenges

Integration Challenges, Wipro’s Integration Services

About Wipro

Wipro Technologies


Wipro – A SEI CMM Level 5 Company

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360 degree services for Providers

R & D

• EPIC, Cerner, IDX, Eclipsys, MEDITECH, Siemens

• Application Management services• Integration Services – HL7Care

Management Portals • Healthcare Analytics• Paperless office solutions• Identity and access management

Healthcare IT Services

• Remote Network Monitoring• Remote desktop support• Service desk and Help desk• ITIL compliance • Security & Risk Management: HIPAA

Infrastructure Services

Global Compliance Center - HIPAA ComplianceAHA certified partner, Fixed fee HIPAA compliance

IT and Non IT Asset Management for HospitalsManagement of Medical Devices from a command center

Clinical Reporting with Business ObjectsMEDTECH NPR reporting alternative

Clinical Process OutsourcingRemote Radiology Services

• Revenue cycle management• Medical coding and billing• Remote radiology services• Procurement, F&A and HR services

BPO Services

Innovation and Value Accelerators

Consult Develop & Deploy Manage & Evolve

Application on Network ServicesAON on Medical Grade Networks - Cisco

Managed Integration Services Shared SUN JCAPS (e*Gate) Integration Factory


Thank You !

You can Interact with Raj Ranganath face to face at HIMSS Booth #2235 (Feb 24- 28)

Raj Ranganath is presenting on the Topic “Enabling EMR/EHR a Unique Pay per Request

Approach”at Booth 581 on Date: 2/25/2008

Time: 5:15 PM - 6:00 PM

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