Electronic Health Records EHRs: Clinical Information Systems - Accenture

The end result promises to be more efficient and effective health care, and result in high performance for health care players.

A few years ago, the Leapfrog Group (made up of more than 170 companies and organizations that buy health care) called upon health organizations to implement computerized physician order entry (CPOE) systems as a way to reduce medical errors.

The efforts of other countries—combined with national initiatives such as anti-terrorism response and an FDA imperative to accelerate the progress of clinical trials—have caused organizational stirs in the Department of Health and Human Services (DHHS). Though substantial funds have not yet been budgeted, DHHS does agree that if the current efforts continue over the next 10 or so years, the United States will have somewhere between 5,000 and 30,000 silos of information that can't be shared.

President Bush and other national leaders have publicly called for development of a national health information infrastructure. The US government developed plans that call for all Americans to have an electronic health record by 2014. The plans so far call for a hierarchical set of local/regional and state networks and finally a national network that facilitate peer-to-peer sharing of patient electronic health record information.

Health organizations are starting to examine the implications of the government's plans. Individual provider organizations will need:

• Their own EHR systems that facilitate clinical process automation within their offices and organizations and also share and access that same information on these networks.
  
  
• Information that conforms to a number of messaging and data and content or vocabulary standards.
  
  
• An understanding of the defined standards that cover a wide variety of data and activities and verification that fundamental and core elements of any planned implementation such as data representation and source level coding are not contrary to these standards.

Accenture's experience indicates that hospitals and health systems will face some fundamental architectural problems with existing technologies as they move towards developing electronic methods of storing and tracking clinical information. These include scalability, reliability, recoverability, interchangeable vocabularies and integration.

Scalability
Health organizations need to determine if a single EHR system will be big enough to support all users with the functionality they want. Architectures in use today do not scale (or at least have not demonstrated scalability) to the EHR requirements. Vendor systems can only be reliably measured by their "largest live implementation." EHR systems scale well until their single online data store develops unacceptable spikes of peak congestion. The numbers of simultaneous sessions and active interfaces correlate to online systems performance.

Reliability
At least in part, health organizations have a goal of replacing paper records that are currently used for the administration of clinical and business processes. Paper processes may technically exist as a downtime procedure. But classic downtime paper procedures are ineffective when procedures have been redesigned to make best use of information technology. And paper charts are frequently misplaced or for some other reason unavailable. Yet, unlike an electronic environment where access to records depends upon system availability, paper charts (if they have not been misplaced) can be available, even though it may require time and effort to find them. The issue of reliability is one that few health organizations have ever truly encountered.

Recoverability
EHR systems need to be instantly recoverable in the event of downtime, or if a failure occurs. Health organizations will need to develop backup plans to provide clinicians with access to critical clinical information that is only available in an electronic form if systems become suddenly unavailable. Emergency care, scheduling and registration, order entry, and clinical documentation are just a few of the work processes that would need to continue seamlessly, even with a primary systems interruption.

Interchangeable Vocabularies
Health organizations are frequently challenged by a variety of code sets or master files that have proliferated across their facilities. Most often, this is due to acquisitions that were never optimized. The US government is starting to prescribe specific vocabularies that will need to be used for HIPAA attachments transactions and the future exchange of electronic patient information between health care organizations. To support a portable, interoperable electronic health record, health organizations will need to replace their local vocabularies and synchronize their use of government-specified code sets.

Integration
Most electronic record systems do not integrate with those of other vendors (and some systems offered by the same vendor aren't even integrated with each other). True interoperability will require that all features and functions work across all applications. The term "semantic interoperability" is now being used to describe a level of integration that facilitates the movement of data between systems. A practical definition of "semantic interoperability" is the interchange of data where not only can the information be transmitted between/among systems, but the receiving system can understand and reuse the information in many different contexts, across all health care information application domains.

Accenture believes that in light of the inevitability of EHRs, all hospitals and health systems clearly need to consider developing electronic methods of storing and tracking clinical information.

Government, industry and patient demands promise to make electronic health records a "when," not an "if," for the US health care industry. All players need to prepare for the inevitable. The change will not be easy and will involve radical change in the scalability, reliability, recoverability, interchangeable vocabularies and integration of clinical systems. But the end result promises to be more efficient and effective health care, and result in high performance for health care players.