As the average hospital today has almost 850+ mission critical applications, the word “interoperability” has now become synonymous with Enterprise Integration (EI).  EI is the goal of connecting software (read: getting to data) from different vendors’ solutions notwithstanding differences in infrastructure technology and application architecture.  Hospitals must connect all manner of disparate healthcare applications while accommodating the unique needs of each EMR/EHA and Back-Office solution interface to keep operating and patient data flowing. At the same time, hospital IT is charged with the growing requirement for both Healthcare Information Exchange (HIE) and Accountable Care Organizations (ACO) while meeting Meaningful Use/Quality KPIs and Business Intelligence objectives. All of these initiatives add another layer of complexity that need to be handled in a confident, productive manner. This is where an Enterprise Integration (EI) Strategy comes into play.

Who Benefits from an EI Strategy and How:

  • The Healthcare Enterprise – Improve care; improve quality; reduce costs
  • Payors – Reduce payments; improve data availability
  • Employers – Transparency; reduced premiums
  • And Most of All – Patients via Patient Safety and Quality of Care
    • Emerging benefits:
      • Back-Office administrative system to help manage costs
      • Self-administration and remote monitoring
      • Business Intelligence: use of evidence-based information
  • Timeliness of care delivery
  • Accuracy of care delivery (reduction of medical errors)
  • Data accessibility (ease of access to all data needed for consultation and treatment)
  • Legibility and accuracy of medical records
  • Reduce duplication of medical tests
  • Enhances continuity of care
  • To integrate data and functionality across a hospital’s applications
  • To transform data into understandable, meaningful, and useful actionable information
  • To keep operational costs within acceptable limits; to allow applications to be added and subtracted as needed while not disrupting operational stability

The Challenge:

As hospitals are composed of many businesses (service lines), each of which may have both core and best-of-breed vendor solutions. Regardless of the reason, individual applications must be integrated with core hospital systems and even other departmental applications.
Even “Integrated Product Suites” or “Integrated Enterprise Systems” are often cobbled together from many independently developed or acquired applications.  Under the covers, even the most closely pre-interfaced application suites have separate supporting database schemas and often even different architectures. In order to interconnect integrated product suites it is not unusual to have to break and reestablish existing “pre-integration” data links in order to smoothly transfer data from one domain to another.
Cross-enterprise applications such as transcription, portals, administrative/HR, Pay for Performance (P4P) and quality reporting, and many others require connectivity across and between core and specialty applications, because the “business” simply demands it.
As such, hospitals have developed “Interfaced” Systems IT-Strategies with a goal (or requirement) to introduce different applications that were introduced for a need of “robust” functionality not available in any of the current systems or Best of Suite/Best of Breed solutions or requirements of a merged Healthcare Entity with many systems in various stages and with various requirements towards and EI strategy.

Approach

Integrated application suites are consolidated through a common Data Model and consistent application design.  Separate applications require an interface capability in each application and connectivity between the applications. Complex IT environments often require the addition of specialized software to manage the flow of data and facilitate business recovery after system outages.  Consider Figure 1 below, here a single vendor application set can still require integration of applications when the vendor has acquired third party products or support delivered Application Program Interfacing (API).  There exist different types of integration: data, functional, contextual, and even semantic.

Figure 1

As hospitals are often organized around departments or functions, and applications were developed to support them, integrating these functions can save time and money.  Consider (graphic) how much time staff spend coordinating supplies, information, and determining what supplies will go next for patient care.  Integrating the necessary systems can help

reduce time spent on these tasks. Integration can help optimize workflows via streamline processes as part of overall business process redesign.  In many cases, workflow re-designs can change processes from serial to parallel which improves both efficiency and outcomes. Moving routine and repetitive functions to automation makes staff available for more productive and rewarding tasks.
Once integrated, applications can then transform workflows.  Hospitals and processes are complex, so workflow models need to include clinical stakeholders and the information they use. Integration can help make information available to those who need it and prevent the same question being asked and documented multiple times. However, not necessarily the same language or terms are used to describe data or events. Systems have to satisfy multiple data owners because they are used by multiple systems.

Components of a Fully Integrated Enterprise

  • Interface Engine controlling data flows between applications
  • Master Person Index: A database and rules engine that contain a unique identifier for every patient in the enterprise , regardless of how many other unique application patient indices exist
  • Single Sign-on with common authentication: a process that Permits a user to enter one name and password in order to access multiple applications
  • Context Management: a process for passing user interface (display) context (patient, physician, user, and even item information) from one application to the other without user involvement
  • Common Code Sets allow for the maintenance and transfer of data that can be used and “understood” in multiple systems
  • Data Warehouse: Permits access of information across the enterprise through use of a central data repository or storage system
  • Semantic Interoperability: data is not only transferred from one application to another, but its meaning is translated to match the receiver

Principles for Healthcare Enterprise Integration

Many hospitals look to guiding principles to establish consistency across their Integration initiatives.
Workflow: integration teams often implemented for one group or department without fully considering downstream and interdisciplinary impacts.  Information could be used for multiple purposes by multiple people.  People other than the supported group might need to change their workflow because of an implemented system. Constant flow of information is needed between different skill sets, each with their own information needs and vocabulary. Consider each departmental or specialty application within the larger enterprise context.
Security: balance between acceptable risk and usability protect the hospitals information.
Adaptability: solutions have to be flexible to address ever changing requirements, procedures, processes, and organization. Consider and EI approach that is based modular structure, e.g., reuse of objects.
Standards: open interfaces and data models delivered through an enterprise-wide governance framework are crucial for an EI approach success. Open standards shields against vendor dependency and is important for protecting the hospital’s IT investments (the move to more componentization relies on standardization).
Performance: it is costly to add scalability as an afterthought. Solutions need to be efficient and service able to grow with need (increase in users, transaction volumes, and data capacity to prevent bottlenecks).
Management: The need for features such as version control, end-to-end visibility, and monitoring become even more critical.

  • Approaches vary from top down or bottom up.   However, most Integration models have four levels:
    • business architecture,
    • information architecture,
    • applications & systems architecture, and
    • technical architecture.

Sample Requirements

Rapidly integrate and analyze business intelligence data from clinical, financial and resource management systems for better operations and improved quality of care. Empower healthcare workers with decision support anywhere, anytime.   Healthcare providers face rising costs, long revenue cycles, bad debt, and charity write-offs. The public demands transparency and accountability. The healthcare industry is shifting to Evidence-Based Medicine (EBM), Pay for Performance (P4P), Diagnosis-Related Groups (DRG) and Consumer-Directed Health Plans (CDHP). Capabilities are needed to quickly integrate and analyze business intelligence data across healthcare and hospital systems. CedarCrestone supports proven Integration solutions for healthcare that empowers providers to:

Unify Clinical Automation with Business Processes

The value of clinical automation systems to deliver real operational and cost benefits depends on the ability to integrate their information-rich data stores with established clinical and operational processes. Using EI solutions, healthcare clinicians and administrators are able to:

  • Simplify compliance reporting, patient administration, and transitions to Electronic Medical Records
  • Improve patient flow models and monitoring metrics
  • Benchmark and track performance against similar facilities
  • Institute clinical care optimization methodologies 

Expedite Access to Critical Information for Better Patient Care

Difficulties lie in searching for and getting access to evidence data. Using EI solutions, healthcare physicians and supporting medical staff are able to:

  • Save precious time in ERs and ICUs
  • Improve decision-support for Computer-based Patient Record systems
  • Streamline and track the effectiveness of business processes
  • Identify and track key patient safety and care quality metrics 

Optimize Resources Based on Demand

Healthcare facilities experience fluctuating capacity. Underestimating demand for appointments and procedures can leave patients waiting, reducing satisfaction and perceptions of care. Overestimating underutilizes clinical staff, increasing costs. Using the EI solutions, healthcare providers have are able to improve resource planning and utilization—based on demand—in areas such as:

  • Use of facilities, including ER, OR, ICU, testing rooms and patient beds
  • Scheduling of equipment and patient tests
  • Shift planning and scheduling of clinicians and support staff
  • Staffing adjustments due to variations in patient census, as well as staff vacations, sick days, holidays, family leave, weather emergencies, retirements, etc.

Control the Revenue Cycle

High costs and fears of lower reimbursements from emerging P4P, DRG and CDHP insurance models increase the urgency to accelerate revenue cycles and reduce the underlying cost of collections. Using EI solutions, healthcare CFOs, financial analysts and accounting professionals have are able to:

  • Gain visibility across functions affecting cash flow, net cash, bad debt and cost-to-collect
  • Improve processes for patient admissions, claims administration, denial management, fraud detection, and insurer contract management
  • Increase cost capture during care delivery
  • Reduce burdens of P4P and DRG tracking, reporting and cost accounting

Summary

This blog deals with some of the basics around why hospitals are giving a serious thought to the current Integration approach and an Enterprise Integration Strategy plays a major role in linking to initiatives like Enterprise Business Intelligence.
While it is important to focus on immediate integrations at hand—it is becoming increasingly imperative to also take a step back and view the enterprise from a “10,000 feet high viewpoint” to enable stronger linkage between IT initiatives to both the clinical and operational business goals, strategies, and measures.
Enterprise Integration (EI) through traditional methods needs to focus on distributed/federated architectures that span multiple entities and disparate business processes. A clear view on the definitions, policies, and standards for EI will help the hospital safely steer to the target destination.