Integrating Integrated Delivery Systems

Bill Briggs, Senior Editor
Health Data Management Magazine, September 2005

Aligning people, process and technology" was the mantra for Parkview Health when the Fort Wayne, Ind.-based integrated delivery system committed to improving its information technology infrastructure to unite an expanding family of care locations.

Parkview Health has electronically integrated its eight hospitals, with 774 beds, in northwestern Indiana. The process began in 1999, when the delivery system's governing board recognized a need to upgrade its I.T. and telecommunications infrastructure, says Pat Thompson, senior vice president and CIO.

"The board believed our strategic direction was to use I.T. and redefine health care in northwest Indiana," she explains. "That direction was built around integration."

At the same time Parkview Health kicked off a project to select a primary vendor in 2000, the organization began improving its telephone and local and wide area networks. Thompson oversaw the parallel tasks, with the vendor search running through 2002.

A paramount need

Many integrated delivery systems have duplicated Parkview's efforts in recent years. As provider organizations form new governance arrangements to deliver expanded ranges of care across a community or across state lines, the need to share information at all points becomes paramount.

While integrated delivery systems report different strategies for enabling enterprisewide access to clinical, financial and administrative data, they agree it can only be done with a cohesive I.T. plan. And deep pockets: the cost of tying systems together with I.T. ranges from tens to hundreds of millions of dollars.

There are more than 460 integrated delivery systems in the United States, and that number is growing, says Charles Bracken, managing director for ACS Healthcare Solutions, a Dearborn, Mich.-based consulting firm. As their numbers continue to climb, so will the need to lean on I.T.

"There is a long way to go, but we are definitely in a round of upgrades, integration and information system advancement, all since 2000," he says. "Most of the integrated delivery systems we work with are on the journey. They are committed to the next level of upgrade, to advancing clinical information systems through a core vendor strategy."

Many are on the road to fully integrating their organizations with I.T., but there are obstacles ahead.

"More integrated delivery systems are implementing I.T. than selecting," Bracken adds. "And many who are implementing have yet to aggressively pursue the operational changes associated with their goals."

How these organizations coalesce has changed over the two decades since integrated delivery systems began forming to compete for managed care contracts.

For example, the 1990s modus operandi of employing group practice-based physicians is giving way to integrated delivery systems looking for ways to tie in doctors without putting them on the payroll, says Laura D. Jantos, principal with ECG Management Consultants Inc., Seattle. That's leading to a more complex problem when it comes to implementing I.T.

Ground-up I.T. strategy

"When a physician is not on the payroll, management can't just say, `Use this system,' " Jantos says. "Management needs an I.T. strategy built from the ground up. And they need a cohesive vision and governing structure."

Parkview Health's vision was putting patient data in the hands of clinicians where they need it-hospital, office or home-in order to truly integrate the integrated delivery system. It was achieved by the decision to standardize on IDX Systems Corp., Burlington, Vt., as the core vendor.

That strategy was a goal, rather than a mandate, Thompson explains. "We conducted a prime vendor search for 18 months. It included specific criteria like any RFP process. We acknowledged we were not looking for one vendor to provide all solutions, but we wanted them to participate in bringing in other vendors for lab, radiology and document imaging. We wanted a partner."

One of Parkview's first steps was a three-month process review to understand how care was being delivered and how to make the most of the Last Word application from IDX.

Last Word became the foundation for the vendor's Carecast system that includes clinical documentation, a single database for a patient's lifetime longitudinal record and bar code-based medication charting.

Carecast also serves as the central connection to all other major information systems, including document imaging, radiology, admission-

discharge-transfer and master patient index. It is the gateway to the long-time financial system from McKesson, which was the original "core" database system, Thompson says.

The document imaging system, from LanVision Systems Inc., Cincinnati-which has an alliance with IDX-was implemented in 2002 and rolled out across the organization. That reflected a decision made early in the integration process to deploy any new applications across the integrated delivery system, regardless of what might be in place at other locations.

Document imaging helped produce early positive results for 1,200 physicians, giving them access to older paper records in their offices and homes, Thompson notes, along with any paper documents for patients going forward.

Data for doctors

The presence of a competing health care delivery system in Fort Wayne is part of Parkview's motivation to continue improvements, she says. Doctors that practice at both delivery systems know patient data is available at Parkview to help them make decisions.

"The critical part is making data available," Thompson says. "That's the challenge with CPOE and evidence-based medicine. We're using data to support physicians and other clinicians, and doing so without interrupting what they do."

Computerized physician order entry isn't in place yet, but some steps have been taken to prepare order sets. Parkview likely will pilot CPOE software sometime next year, Thompson adds.

Parkview Health's I.T. infrastructure investment target from mid-2001 to mid-2005 was $75 million. The organization has stayed within that budget, which was set down by its governing board at the outset.

As noted by CIOs and other observers, bringing these large health care organizations together typically requires: collaboration from the CEO level on down; evaluating and changing processes; and elaborate I.T. infrastructures.

Change is the operative word. It applies to all three tasks and can lead to wholesale shifts in I.T. purchasing philosophies. Change also has been the rule for vendors.

Information technology vendors historically developed their products in much the same way providers laid out their care strategies. "Delivery systems have been developed for acute or ambulatory care," says Jantos, the consultant. "They usually needed different information systems to manage each."

Increased effort

In recent years, a growing number of vendors increased their efforts to provide products for the entire integrated delivery system, from financial to scheduling to clinical applications.

As these vendors developed their products, many approached the task from either the acute or ambulatory angles, Jantos notes. "The problem was that most vendors had strengths in one area but not the other."

As a result, some integrated delivery systems went with "best-of-breed" strategies, choosing the "best" application for each need. Those organizations face significant investments-in dollars and other resources-to integrate or interface multiple systems.

There's little question that vendor information systems have evolved since the early days of integrated delivery system formation and many have sophisticated products on both sides, Jantos and others say. But some still have areas of weakness.

Another long-standing concern for integrated delivery systems regards vendors that have grown by acquisition.

The question arises whether their products were developed on one database or if vendors acquired components and redeployed them in their original form.

Most integrated delivery systems fall into one of two vendor relationship categories. "They have a strong preference for products from one vendor that ties to the core strategy across the network, because of maintenance factors or negotiated costs," Jantos says. "Or it's modified best-of-breed with major information system components from one vendor."

Big payoff

The big payoff for integrated delivery systems that invest in I.T. is transferability of data, industry observers say. Another benefit: centralized functions, such as one I.T. department for an entire organization. That's especially important to physician practices that don't have the staff or infrastructure to support a complex I.T. strategy.

In 2001, top executives at Halifax Community Health System of Daytona Beach, Fla., decided that reaping such benefits meant pursuing a prime vendor strategy to link its 764-bed hospital and 50 other locations in Volusia County. Since implementing core information systems from Meditech, Westwood, Mass., Halifax is spending $3 million to $5 million annually on new technology, says Lori DeLone, CIO.

The integrated delivery system includes clinics, an HMO and PPO, hospice, and financial services, all in various locations. The organization plans to open a satellite hospital in Port Orange in September 2006.

"The first big step to a truly integrated delivery system was Aug 1, 2002, when we brought the Meditech core systems live," DeLone says.

Since deciding to stick with a core vendor, Halifax has held "reasonably true to that," she adds. "We felt that the ability to share information across the continuum of care supercedes the need for best functionality within each service area."

The Meditech product package includes lab, pharmacy, electronic medical records, order entry, billing, accounts receivable, scheduling and ADT, and general financials. Halifax's move to Meditech signaled a shift from mainframe-based legacy information systems to a client/server-based distributed network environment. So far, DeLone has been satisfied with the results, but there likely will be pressure to acquire other applications down the road.

Keeping focused

"It's difficult to keep people focused on the end-state of clinical data integration," she says. "And it's hard to stay tuned in. Human nature is to want the best available functionality. That's a constant challenge."

All it takes is for someone to hear about the virtues of a new application, says Kevin Noel, I.T. project manager. "Most don't understand the benefits of sticking with a core system. They don't understand that's how they have information available across the organization."

The alternative is integration costs. "Massive integrations is where we came from," Noel adds. "Now we're trying to leverage the fact that we're going with Meditech to reduce those costs."

Halifax has taken advantage of the lay of the land in Florida and uses wireless networks extensively. Tsunami wireless WAN technology is from San Jose, Calif.-based Proxim Corp. Tsunami works among the organization's remote locations because the Halifax service area's surface geography is flat.

The wireless LAN at Halifax Community Hospital is from Nortel Networks, Richardson, Texas.

One of the key challenges facing Halifax and other integrated delivery systems is taking the time to leverage the installed base of applications, DeLone says. "It's a journey-it's not done. Now we have to take advantage of all the tools already in place. We've found historically how easy it is to put something in and move on and not take advantage of it."

Mobile challenge

Another challenge is taking advantage of mobile technology. One big issue has been access to computer terminals, says Neil Oslos, M.D., associate director of Halifax's family medicine residency program and chair of its physician technology advisory council.

Halifax has crammed in workstations and personal computers, but physicians still have trouble finding one when seeking patient information. "The hospital is older and there's not much excess space," Oslos says. "We're frequently filled to capacity so we don't want to give up care space."

Access to patient data in hospital rooms is now possible via technology from PatientKeeper Inc., Boston. Physicians use PDAs to access data, which is transferred from the Meditech system.

About half of Halifax's 50 primary admitting physicians tested the PatientKeeper system earlier this year, Oslos says.

Full rollout began in March. PatientKeeper is an example of a non-core application that was chosen because of functionality, and it integrates well with Meditech, Oslos says.

Access to data is driving Salt Lake City-based Intermountain Health Care to revamp its I.T. infrastructure. The integrated delivery system, which has 21 hospitals, about 100 clinics, 600 employed physicians and a health plan with 500,000 members, is standardizing on a core vendor. But Intermountain wants to keep its homegrown core clinical information system in place.

An agreement signed this summer with GE Healthcare, Waukesha, Wis., outlines how the vendor will build on the existing architecture as it upgrades the integrated delivery systems' information systems, says Marc Probst, CIO.

The homegrown system includes a structured health data dictionary, decision support and a coded clinical data repository.

When Probst joined Intermountain in 2003, management wanted him to explore a new electronic medical records system. The search helped convince Probst and other executives that some of the organization's I.T. should be retained.

Preserving architecture

"It's not that there weren't good companies and products," Probst explains. "But we feel the underlying architecture we have is so superior around data analysis and decision support that we'd be taking a step backward if we didn't proceed with that architecture."

The homegrown clinical information system was developed 30 years ago and was available across the integrated delivery system. But the original was designed to support episodic care, not to manage longitudinal patient data, Probst says.

"The longitudinal view of data will be very important to physicians and hospitals," he says. "Our 21 hospitals don't have the same level of technology today. When we get done with this project in the next five or six years, they all will have the same technological capabilities."

The new information system will enable Intermountain's rural hospitals to access data tools in specialty areas, including radiology and pathology.

The GE Healthcare agreement is part of a broader collaboration spanning 10 years and including joint development of clinical software.

The resulting applications also will be made available to other health care organizations. Intermountain has consolidated its I.T. department into one, 650-person unit serving all member organizations.

Common systems

The move to standardize vendors yields similar rewards for other integrated delivery systems.

At Denver Health, for example, standardization has meant one central network for voice and data, says Gregory Veltri, CIO.

The integrated delivery system includes a 396-bed hospital, 10 family practice clinics and 13 school-based clinics. Denver Health also serves as the city's public health department.

The organization also uses one common patient identification number, so wherever a patient is seen clinicians have access to a common medical record.

Siemens Medical Solutions, Malvern, Pa., is the core vendor, having signed with Denver Health to deploy an electronic records system in 1999. An upgrade to the Soarian product line is under way. The integrated delivery system is striving to reduce the total number of information systems. "We are centralizing toward a single vendor," Veltri says. "I don't know if we will ever get to one database, but that would be the perfect world."

Denver Health has both structured and unstructured views of electronic records, he explains. Siemens has document management, which enables scanning of paper records. Then there are the structured views, such as lab, pharmacy and radiology encounter data that flows into the core system through electronic interfaces. "We have a Web-based `dashboard,' so it looks seamless to users," Veltri says.

Integration hasn't come cheaply. Denver Health has invested about $225 million in I.T. since 1997 and adds about $750,000 to its network infrastructure annually.

Success was due in large part to a three-phase approach to the I.T. integration task, beginning with its infrastructure. "The infrastructure was broken when I came in," Veltri says. "We had a couple hundred hours a month of downtime." The overhaul included new fiber optic lines for voice and data.

The second phase was to implement Siemens' patient accounting software, which "increased collections and improved capital," he adds. "Now we're in the third phase: delivering data in a more real-time fashion."

Sidebar

Clinicians hold key to success

Persuading integrated delivery systems' governing boards to make multi-million dollar information technology investments isn't the toughest sell when it comes to enterprisewide I.T. projects. The delicate part these days is convincing clinician users to change the way they do things and learn to use a new information system.

As with any new information system, change management and user participation are keys to successful rollouts. At the integrated delivery system level, the challenges are magnified, observers say, but the rewards might be sweeter.

At Fort Wayne, Ind.-based Parkview Health, I.T. is part of the integrated delivery system's worldview. The systemwide rollout of I.T. from core vendor IDX Systems Corp., Burlington, Vt., has been a group effort from the largest of its eight hospitals to the smallest.

"We've been involved all along the way as a community hospital," says Bridget Johnson, vice president of patient care at 45-bed Whitley Hospital. "We have been part of vendor selection and very involved in operations."

On a micro level, clinicians also have been in the mix, including nurses who have been "involved from the get-go," Johnson says.

Part of Whitley Hospital's success came from change management training up front. It also came from determined leaders who wouldn't take "no" for an answer when it came to implementing the electronic records system.

"Some nurses said, `I can't do it, I'm going to quit.' But we worked with them with roving educators. It wasn't easy and we told them it wouldn't be."

The I.T. implementations have all gone toward making Parkview Health as safe and efficient as possible. The organization has succeeded, Johnson says, through collaboration.

"I've worked in other delivery systems and I've never before seen clinicians and I.T. staff so involved together," she notes. "We all worked together and listened to and respected each other. And no one ever said, `We can't do that.' "

Open minds

Halifax Community Health System of Daytona Beach, Fla., has been fortunate to have an open-minded physician staff-so far, says Neil Oslos, M.D., associate director of Halifax's family medicine residency program and chair of its physician technology advisory council.

Doctors have embraced mobile technology, for example, and are using PDAs for in-room access to patient information via an application from PatientKeeper Inc., Boston, which draws data from core information systems from Meditech, Westwood, Mass.

`We're somewhat blessed," Oslos says. "The majority of our doctors think we should be doing more with I.T."

Like others, the integrated delivery system has a long road ahead. Few of the organization's physicians are entering progress notes directly into the electronic records system, Oslos says. Most still are using paper.

Sidebar

Narrowing to core vendors

When provider organizations come together to form integrated delivery systems, they bring a range of health care skills to the party. They also can bring a dizzying array of information systems and applications.

One of the thornier bits of integrating such organizations with I.T. is deciding what to keep and what to replace.

University of Pennsylvania Health System, for example, grew in "fits and starts," says George Brenckle, CIO at the Philadelphia-based integrated delivery system with three hospitals totaling 1,155 beds and a faculty physician practice with about 1,000 doctors.

"Each entity brought its own infrastructure," Brenckle says. "In the mid-1990s we had an incredible hodgepodge of systems and technology infrastructures."

In 1998, with the three hospitals in place, the organization began a vendor standardization plan, Brenckle says. Until then, the I.T. purchasing style was best-of-breed and "we tended to have one of everything," he adds.

But managers at the integrated delivery system were hesitant to impose too many restrictions on member organizations. "We didn't feel we could dictate that everyone should rally around a single application," Brenckle says, "or that we wanted to say it's `our way or the highway.' "

Instead, University of Pennsylvania Health System chose a gradual approach and is addressing new applications across the organization as they come up in individual hospitals. The organization spends about $5 million in capital funds annually on I.T.

Regardless of the pace, integrated delivery systems should work toward an "anchor" vendor, contends Charles Bracken, managing director at ACS Healthcare Solutions, a consulting firm in Dearborn, Mich. "It's imperative to take advantage of a vendor's research and development and reach the level of sophistication that current information systems are rising to. The best way is to work with a core or anchor vendor. Even if it's a core `suite' strategy, they still need a central vendor."

University of Pennsylvania Health System's suite of core vendors is long, but it reflects reductions from the earliest days of its existence. The list includes:

General financial: Lawson Software, St. Paul, Minn.

Hospital accounting: Siemens Medical Solutions, Malvern, Pa.

Computerized physician order entry and clinical decision support: Eclipsys Corp., Boca Raton, Fla.

Radiology: IDX Systems Corp., Burlington, Vt.

Pharmacy: McKesson Corp., San Francisco.

Two electronic medical records systems are in place. The ambulatory system is from Epic Systems Corp., Madison, Wis.; the acute system from Eclipsys. "We did that partly because it wasn't clear one vendor could do both in the late `90s," Brenckle says.

The ambulatory version will become the longitudinal patient record storehouse. Brenckle says he wouldn't go with two vendors today, but he faces a dilemma common among other integrated delivery systems. "We don't want to undo all that work."

The organization's master patient index is from SeeBeyond, Monrovia, Calif., as is an interface engine. "When you take a horizontal approach to integration," Brenckle says, "you're very dependent on interface engines."