Case Study p$.89$

An integrated delivery network $($IDN$)$ serving a large urban and rural demographic area is using separate EHR systems. Some specialty departments have also purchased their own systems for documentation. Unfortunately, this means that when the information is collected in the inpatient setting is not available when patients are seen in the IDNs outpatient clinics $($and vice versa$).$ The clinicians need this info in order to be better informed about their patients and provide optimal care. Additionally, Meaningful Use $($MU$)$ requirements for problems medications and allergies, as well as the new chronic disease initiatives that the IDN is implementing for its patient population, are being hindered by the separate systems. The clinicians are able to access both EHR$$s$,$ however, this is cumbersome to be trained on multiple systems, log in and out of different systems, and navigate to the needed information. There is also a safety risk that the clinician may not select the correct patient when moving between systems. A coordinated clinical decision support system is also challenging because the disparate systems use different coding systems and don$$t share most of their info. For example, congestive heart failure patients cannot be linked to the ambulatory medication list and recent vital signs measurements to run the IDN$$s standard care process models.

The IDN will not be able to replace either EHR in the near future and that, even so$,$ there will still be issues with integrating information from the specialty care systems. It decides on a strategic plan to create a clinical data repository $($CDR$)$ that$$s fed with high$-$value data from each of the clinical systems. The outpatient EHR$$s master patient index is already being used as the unique identifier for most of the IDN$$s systems, so it can be incorporated into the new CDR$.$ A robust IE is implemented to supply data from the clinical systems to the CDR$.$ To normalize the different terminologies used in various systems, the IDN engages a terminology$-$services vendor to provide a central data dictionary for the CDR and map the concepts from the current systems.

The second phase of the strategic plan is to build a CDS system on top of the CDR to develop and maintain enterprise patient$-$care rules. As the rules are executed, their results will be both sent through the IE to the existing EHRs and stored in the CDR; storing the decision support results in the CDR provides a link to the supporting data from all clinical systems, which can help with rule$-$triage and maintenance.

Another effort in this phase is to provide clinician views into the CDR$.$ The IDN plans to build data services, possibly based on FHIR resources, that can be called by third$-$party EHRs to display longitudinal, enterprise$-$wide patient data from within the EHRs. There$$s a plan for a simple web$-$ and mobile$-$based applications to be developed using these data services, and will be available as stand$-$alone or within the current EHR. The IDN will use SMART to provide the user and patient context from the EHR to these viewing apps so that the clinicians won$$t have to log in twice and search for the patient.

This situation occurs in many hospitals across the nation. Describe the advantages and disadvantages of the case above.

You are the chief medical informatics officer $($CMIO$)$ for the organization. You$$re asked to comment about how the technical plans will affect clinicians. Based on the case study, how do you respond?

The organization receives a $$3$ million gift from an informatics benefactor. You are an informatician in the organization. What would your technical priorities be to remedy the issues in the case study