Systems Integration: The Electronic Records Linchpin

Greg Gillespie, Managing Editor
Health Data Management Magazine, May 2005

The term "electronic medical records system" is something of a misnomer. While many health care information technology vendors sell products by that name, no such software comes in just one box. In reality, it's the combination of various clinical information systems-documentation, dictation, computerized physician order entry, laboratory, radiology and many others-that together make up an "electronic medical records system." Consequently, all the various systems must be made to work together to present physicians and nurses with the complete record of a patient.

Just like a linchpin is used to hold together a complex set of parts, systems integration technology bands together the clinical applications needed to create an electronic medical record. The technology enables CIOs to facilitate data sharing among information systems or present disparate data in a common application.

Many say the solution to bringing systems together is to go the "single-source" route-buying all clinical applications from the same vendor, which offers them in an already integrated fashion. However, most organizations that choose the single-source strategy quickly discover that one vendor simply cannot offer all the requisite systems. Or they find clinicians in some departments want to use an application they consider better than that offered by the single-source vendor.

Deceptively simple

What clinicians see when they access electronic records is a deceptively simple view of an information technology infrastructure. Data is neatly arrayed in columns and tables, and a few mouse clicks can set off an amazing chain of events-lab tests are ordered; radiology images pop up on screen; prescriptions are checked and sent to the pharmacy in a matter of seconds.

Typically, though, electronic records users don't know the effort required to get all the information from disparate systems in one place at the same time.

For example, do clinicians using the electronic records system at Montefiore Medical Center know that their single view of clinical and demographic data requires more than 400 interfaces to operate? Or that each time they click "send," bits and pieces of data are being parsed to numerous information systems through the delivery system's interface engine?

On a mission

"We used to joke that our bathrooms would be paperless before our nursing units. But when we decided to implement an electronic record, we really went on a mission with our information systems," says Jack Wolf, Montefiore's CIO. The Bronx, N.Y.-based, two-hospital delivery system uses Carecast electronic records software from Burlington, Vt.-based IDX Systems Corp. and an interface engine from Software Technologies Inc., Monrovia, Calif. "If you really want to create a seamless electronic record, there is an enormous amount of work to be done before that's even remotely possible."

Behind every successful electronic records implementation is a backstory of systems integration-a tale full of inspiring highs and depressing lows, heroes and villains, treasure in the form of clinical data and sometimes vendor paychecks.

If the industry is serious about widespread adoption of electronic records, this is a story that will be told again and again. CIOs and I.T. experts agree that integration technology-coupled with increased and uniform use of messaging standards-has made systems integration a more manageable task.

Still, there are many hurdles-some technological, others conceptual-before integration delivers the type of seamless electronic medical records systems proponents envision as being standard technology.

The rise of electronic medical records systems is causing is a shift in the industry's approach to systems integration, says Wes Rishel, vice president and research area director at Stamford, Conn.-based Gartner Inc. Rishel also serves on the board of directors at Ann Arbor, Mich.-based Health Level Seven, which develops the health care industry's de facto electronic data interchange messaging standards.

Many health care organizations still treat systems integration as an afterthought to be addressed using ad hoc techniques late in the stages of implementing or upgrading an application, according to Rishel. Gartner refers to this approach as "pick up sticks" integration. Like the child's game, each integration project is designed to cause the least disturbance to the pile of applications, interfaces and existing business processes.

"The most common approach even today is using proprietary-and sometimes obscure-communication protocols to move data from one system to a file server and then into another system," Rishel says. "That might work fine when passing info back and forth between information systems, but now there is a person viewing that data who needs to look at information from multiple systems in one window, and also needs to perform transactions based on that data.

"That requires systems integration based on workflows and business processes. Instead of point-to-point connections, organizations need to use integration strategies that provide the flexibility to integrate data in a user interface."

Service architecture

Some organizations are starting to tackle systems integration using a concept called "service oriented architecture." Service oriented architectures are designed to couple together interacting software agents, or business components. They utilize a set of simple interfaces that can be re-used across different computing platforms and messaging standards.

The engineering discipline breaks up application business logic into a set of granular "services"-chunks of programming that provide business functionality-that may be used by different applications.

CIOs and other I.T. executives are finding that "pick up sticks," by comparison, does not provide the flexibility required to support electronic records systems, especially in light of the push to create interoperable electronic records. The problem is that one size does not fit all when it comes to systems integration, says Darren Dworkin, chief technology officer at Boston Medical Center.

The typical clinical messaging strategy has been to enable little systems to feed information into big systems, such as clinical data repositories or hospital information systems. But that strategy doesn't work well in an environment designed to support physician workflow, Dworkin contends.

"There was a time when we thought the best strategy was to interface all our systems and present all the data we had to physicians-but physicians pushed back," Dworkin says. "What they really need is `simplified' data they can process quickly."

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