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General Topics in Healthcare Technology

Overview

When addressing consumer-driven healthcare, one should consider the following environmental factors:

• Managed care penetration

• The dominance of a few healthcare organizations or many highly competitive healthcare organizations

• The risk threshold for technology investment

• Current organizational structure

Consumer driven healthcare requires easily accessible information for all stakeholders and an environment of collaboration, all requiring technology and application investments. Consumers expect to be treated respectfully and not continually beaten down by inefficient processes, or incomplete or inaccurate information.

Organizational Impact

Access to more healthcare information by consumers provides the opportunity for greater involvement in the evaluation of treatment options and participation in care. An educated consumer threatens the authority of physicians and changes the relationships with other stakeholders.

Technology and Applications:

Technology Today

A key requirement to support consumer-driven healthcare is accessible information. Browser-based computing is the most critical advance that will make this happen. Additionally, there are various standards and technologies, such as the adoption of a transaction standard, the use of service-oriented architectures for application development, and the use of XML.

There are several quite mature technologies to support customer service and support, (e.g., interactive voice response, computer telephony integration) so that even healthcare organizations that are more comfortable with proven technology should feel confident using these technologies. Healthcare vertical portal functionality is far less stable, but there are some specific capabilities- brand medical content, payer organization links and laboratory links that are more mature.

As technologies change, so do the healthcare business applications. Many vendors are re-architecting their applications to address the need for information exchange among applications. Investments in administrative applications are necessary to improve efficiency and support consumer self-service and clinical applications, as well as to capture critical information.

Future Technology

There are many other promising technologies on the horizon for healthcare organizations, but none are without risk. Part of the technology strategy-development process must include the evaluation of the maturity of the technology and the healthcare organizations’ s level of comfort and ability to take the risks that are inherent in less stable technology. For example, Internet appliances currently have limited visibility, but according to Gartner, it began to take hold in 2005, and be widely adopted by 2008. E-mail between and consumers and physicians, as well as Web chat, have some market visibility, but even greater value will be realized when these capabilities are supported by wireless technology, which will be more widely available by the middle of the decade.

Healthcare and Mobile Computing

Healthcare organizations are beginning to recognize the potential benefits of mobile computing, both synchronized and wireless. Mobile computing includes the capability to capture and access information at the point of care, Healthcare organizations looking to move forward with mobile computing face many choices, including which technology and management approaches to select, which vendors and service organizations to pick and which emerging standards to support. How to deal with ensuring security currently remains a major challenge.

The Mobile Healthcare Alliance was formed to assist Healthcare organizations with many of issues they face regarding technology. Their mission is to assist healthcare organizations define their needs, understand regulatory requirements and take advantage of best practices. A major initiative of the Mobile Healthcare Alliance is to help increase the adoption of mobile computing in healthcare. Although founded primarily by vendors, the Mobile Healthcare Alliance asserts that its functions as a neutral collector, analyzer and disseminator of information, and as such is open to all healthcare organizations, and health-related parties, including medical device and mobile telemetry manufacturers, pharmaceutical companies, systems integrators and government agencies.

Most Healthcare organizations are still waiting for their vendors to provide evaluation versions of upcoming products or are involved in pilot studies and are just now attempting to gain feedback from practitioners. Most vendors are only in the early phases of committing to a particular wireless approach. It is still too early for healthcare organizations to have to make major decisions about their wireless strategies, and in many healthcare organizations, adoption of PDAs is still more or less a grass-roots effort with little central decision-making involved.

The Role of Orders in The Delivery of Healthcare

It is in the order-management process that the physician’s diagnostic thought processes are transformed into actions. It is during order entry that documentation of what has been done is effectively captured. This is the time when automated assistance can be of the greatest benefit to the physician to help ensure that the care being provided is appropriate and cost-effective. Additionally, the creation of an order represents a key opportunity to perform “on-the-fly” education by offering the physician advisories based on the particular clinical situation being managed at the time. The order entry process is the single, most cost effective point to deal with managing the overall cost of handling a patient’s disease.

As care delivery organizations migrate from paper-based models of operation to automated ones, it is order entry, and more specifically physician order entry that represents the single process that will most determine what value the organization receives from its automation efforts. Care delivery organizations that carefully plan their order automation efforts and integrate them into an overall long-term strategy to achieve a computer-based patient record system are positioning themselves to take maximum advantage of the benefits offered by clinical healthcare automation systems.
 

Order-Entry Systems and Vendor Selection

Order entry is an essential element in the development of a computer-based patient record system. In traditional order entry systems, nurses or clerical staff key in orders that physicians have handwritten in a patient’s chart or provided over the telephone. Physician order entry systems are used by physicians to directly enter the orders themselves, at the point of care, at the nursing station or remotely via a browser. Point of entry systems eliminates handwriting errors, and limits other mistakes that can lead to adverse drug events.

Gartner Group evaluated eight well-known Order Entry/Point of Entry vendors to gain an understanding of the software marketed by each. The vendors evaluated were:

• 3M Health Information Systems

• Cerner

• Eclipse

• Epic Systems

• IDX Systems

• McKesson

• Per-Se Technologies

• Siemans Medical Solutions Health Services

These vendors were evaluated and compared based on the following criteria:

• Order-Entry Utilization

• Order-Entry Flexibility

• Order-Entry Continuum of Care

• Other-Order Entry Functions

• Order-Entry Decision Support

• Physician Order Entry Status

• Physician Order-Entry Functionality

A= Very Good Meets all Criteria                           B= Good Meets Most Criteria
C= Adequate, Meets Some Criteria                       D= Meets Minimal Criteria

All the above vendors provide order entry as an integrated component of a computer-based patient record system or integrated set of clinical applications within enterprise wide healthcare information system. All mentioned vendors also support medication orders as well as nursing and therapeutic orders. Cerner, Eclipsys, Epic, IDX, McKesson, Per-se, and Siemens provide clinical documentation at the point of care. Among the vendors that provide clinical decision support built into the order entry application, all provide real-time user feedback and the ability of the user to organization to create and modify rules.
Each of these vendors provides interfaces between the order entry system and its own third party laboratory, pharmacy and radiology systems. All also support modification of application software by the customer’s IS department and allow some modification by individual users.

Advice to our clients

• Care delivery organizations should evaluate vendors that offer order entry and physician order entry as part of an integrated computer based patient record system.

• The selected vendor should be able to provide the same functionality in both physician order entry and order entry.

• Risk-averse organizations should select a vendor that has a minimum of five live customer sites with integrated decision support, patient context support, user preferences and multiple medical specialty templates.

• Less risk-adverse organizations should select vendors that can provide the majority of their organization’s physician order entry capabilities immediately, and remaining capabilities within a timeframe that matches the organization’s long-term plans.

• A top indicator of a successful vendor is that vendor’s ability to install systems in a non-academic environment where they do not have the advantage of having their system’s use mandatory by residents.

The Information Broker

The information broker is a type of high level middleware that facilitates the communication between different applications by negotiating a variety of native data formats and communication protocols; they help ensure timely and reliable delivery of message from one application to another. Interest in information brokers in healthcare has increase due to several converging trends:

• Supporting the technical requirements for e-health initiatives including Web enablement of legacy applications, inter-enterprise workflow, and support for XML as well as Internet protocols.

• Health Insurance Portability and Accountability Acts and the integration architecture they necessitate.

• The need to integrate a large variety of similar healthcare systems and applications.

The key to reducing the complexity and expense of integrating multiple applications is to replace ad hoc approaches to application integration with a systemic approach. Application integration should be thought of as a discrete discipline, independent of any particular development project. The key to achieving this systematic approach is by way of the high-level middleware known as the Integration Broker.

The information Broker is a type of system software, which is generally running on dedicated hardware. Doing this frees the application developers from needing to know the number and location of the target applications, or the variety of native data formats and communication protocols they support.

Integration Middleware and the Healthcare Industry

The healthcare industry has been an early adopter of integration middleware. Many care delivery organizations acquired their first integration broker software bundled with departmental application that needed to be interfaced with the organization, patient accounting and order entry applications to deliver their full benefits. Information brokers have also found widespread use in payer organizations, primarily in claims adjudication systems. Information brokers are evolving rapidly to handle these new e-business requirements. This evolution includes support for:

• Request/Reply Communication between applications
  Robust support for composite applications requires a high-performance implementation of a request/reply relationship between the requesting and responding applications.

• XML and Internet Transport
            o An integration broker should be able to import the various forms of XML schemas to
              its message repository, so that the XML can be viewed and edited via the graphical
              user interface.
            o XML schema supported should include XML document type definitions, Microsoft’s
               Extended Data Reduced and W3C’s XML Schema definition language.
            o To support e-health transactions, integration brokers must support more than TCP/IP
               sockets typically used for inter application communication in LAN environments.

• Secure Exchange of Information Across the Internet
  The foundation for secure B2B e-health transactions is the use of public-key cryptography as the mechanism by which communicating parties authenticate one another.

• Business Process Management
  Unlike most application-to-application integration encountered in healthcare, B2B e-health processes take significantly longer and may involve manual processes. Managing complex business processes requires:
           o Access to business process definitions, created at design time, usually with a GUI
             based tool
           o Tracking the progress of each runtime instance of a business process
           o Reporting on process instances that are behind schedule.

What IT Professionals should look for When Evaluating Integration Broker Software

• Message Transport
  An integration Broker must support a wide variety of communication protocols. The capability of some integration brokers to handle B2B integration, using the Internet and appropriate protocols for message transport, is becoming a major differentiator.

• Technical Adaptors
  An integration broker must support a library of adapters that make it appear that these “closed” applications are sending and receiving messages.

• Architecture
  Scalability, availability and reliability must be evaluated, as well as the power and ease of use of debugging and scripting features.