EMRs & Clinical Integration: Best of Breed or One Vendor?

	Intermountain Medical Center, Salt Lake City Center of Salt Lake City, is working to move from disparate best-of-breed EMRs to a single-vendor system—eventually.

In a multiple-EMR environment, is it smarter to keep your existing investments working together while adding best-of-breed IT systems, or to start over with a single-system approach? This is a question facing more facilities as EMR systems mature and the meaningful use program dictates to some extent which systems and combinations of systems will qualify for incentive dollars.

"I find that even where we can achieve syntactic data integration between EMRs, we also have the semantic hill to climb of one EMR expressing 'blood pressure' versus another EMR, which only knows the two separate concepts of 'systolic' and 'diastolic'—just as one example," says Seth Bokser, MD, MPH, a pediatric hospitalist who has led an integrated EMR implementation at University of California, San Francisco (UCSF) Medical Center.

UCSF currently has specialized inpatient EMRs for perioperative/anesthesia, ED, transplants and perinatal care, as well as multiple ambulatory EMRs, says Bokser, who is also medical director of IT at the UCSF Benioff Children's Hospital. With significant investment in an enterprise integration infrastructure and single-sign-on technology, UCSF has been able to make its disparate EMRs work together to optimize care for patients across the continuum. Still, data sharing has been incomplete and the organization has often had to sacrifice structured data for text conversion, Bokser admits.

UCSF recently decided to move from its best-of-breed EMR environment to a single-EMR approach to ensure seamless data sharing across the enterprise. "Currently, we still have these best-of-breed systems, but we'll be replacing most of them over the next couple of months," says Bokser. UCSF is just beginning a rollout of an Epic Enterprise EMR system across the enterprise with its first go-live occurring this month.

Organizations that intend to stay with disparate EMRs should make sure they have the IT expertise, an appreciation of the investment required and the fortitude to rise above the challenges. For example, Bokser reports that in UCSF's best-of-breed scenario, it was difficult to get optimal data conversion, both syntactically from a data structure perspective and semantically from a clinical perspective. "People should recognize that with today's EMR technology, best-of-breed integration is a lot of work. It's a noble pursuit, but a big hill to climb."

A one-system wish

Intermountain Healthcare, a system of 20 hospitals based in Salt Lake City, has been using a pair of legacy EMR systems that harness clinical data, integrated to varying degrees within two central patient databases. Although the current infrastructure can leverage 30 years' worth of inpatient data in the homegrown database and provides rich clinical decision support, continual work is being done to transfer to a single EMR system, says Stanley Huff, MD, CMIO of Intermountain. The organization, which includes more than 900 multi-specialty doctors and more than 150 clinics, is embarking on a systemwide transition to a single-vendor EMR system (GE).  

Along with its legacy inpatient EMR system developed in house, Intermountain uses a separate EMR, co-developed with 3M, in its outpatient environment. The systems use separate databases connected by HL7 version 2 interfaces to provide high-level clinical decision support, says Huff.

Intermountain's dual-EMR system can pull in information from ancillary hospital systems (Sunquest), pharmacy (McKesson), radiology information system (Agfa) and oncology (Varian), according to Huff. This is not the infrastructure architecture that Intermountain dreams of, he admits: "We would prefer to have one system and one database."

Connected by HL7 version 2 interfaces, the inpatient and outpatient EMR systems act as one. They can show discharge summaries, informational notes (from inpatient stays) and the time when a patient was admitted. Internal medical context and medication lists help provide a continuous, seamless patient record in outpatient and inpatient settings. "It's not the architecture we advocate, but it's working well and value is seen when a patient's data can be viewed from one environment in another and vice versa," Huff says.

The infrastructure has its issues, including difficulties reconciling the codes and medical terminology used in the different EMRs, says Huff, echoing Bokser's sentiment. To ensure consistency of terms, Intermountain employs 10 FTEs to maintain and map the codes and terminology to match clinical data in the systems.

The major obstacle to a one-system approach has been the central patient database, according to Huff. An equally important challenge is keeping data synchronized across systems. At Intermountain, all interfaces are double-teamed in case the system goes down. This means that when data are entered into the integrated system, it simultaneously puts the data into a separate, temporary queue, where data wait until the system is online and available for processing, according to Huff.

"It's a never-ending process of interfacing," says Huff, as Intermountain makes changes and adds data. "Adding new interfaces and data requires more mapping of terms."

Intermountain will go live with the first applications of its new single system—problem lists and drug allergy/intolerance modules and physician order entry—later this year and eventually plans to turn off both legacy systems.

When one EMR is not an option

Hospitals and health systems in rural/community space may have no choice but to embrace multiple EMRs. "For a community hospital, there are few products that will fully integrate to satisfy every clinical piece of the puzzle," says Neil Meehan, CMIO, assistant director of emergency center at Lawrence General Hospital in Lawrence, Mass.

Although Lawrence General Hospital has decided to roll out a hospital information system/EMR (McKesson) this year, Meehan says the 200-bed community hospital is still in a situation where it's without a complete integration infrastructure. "I'm not sure they exist for a community hospital. For many community hospitals, the large integrated products may not be financially feasible. We try to get a state of integration and realize that the enterprise systems geared towards the community do not have nearly the functionality of niche systems vendors. This makes the decision much more difficult since the trade offs are more significant."

According to Meehan, niche systems are more important for community hospitals because enterprise vendors can be cost-prohibitive to providers. "To me, adding niche EMR systems is another layer of strategic thinking as you weigh against interoperability of integration," says Meehan. For example, Lawrence General's ER products will require six interfaces to stay tightly integrated with the McKesson system, yet the current state of the system's ED module is an unacceptable alternative, says Meehan.

Until enterprise vendors build on niche elements in their EMR technology, organizations might have to rely on third-party interface builders that have more sophisticated tools to get over interoperability barriers, according to Meehan. For example, Lawrence General is looking into integrating OB/GYN and anesthesia modules into its EMR infrastructure and may hire a third-party to integrate data from pre- and postpartum services in the hospital's EMR.

Lawrence General also is using an integration engine (CorePoint) to map to Picis PulseCheck ED information system data to the EMR, Meehan states.

"Many enterprise vendors at this time are only doing what's necessary to qualify for meaningful use status, but not above and beyond that," says Meehan. "Things are getting better, but it's hard as a community hospital to have a robust system without multiple integrations."

The more niche integration an organization has, the more IT expansion it will need, says Meehan. Each integration comes with costs, more parts and more strings: "Because it can become a domino effect, you need to plan before you change any system," he adds.

More organizations are weighing the costs of continued integration issues among niche systems against the up-front costs, training and potential productivity hits—and eventual benefits—of a single-vendor approach. Whatever their final decision, IT leadership needs to offer humility in the changing environment and "don't make your users or your patients pay the price for coming up short," says Bokser.