Chat with us, powered by LiveChat 1. Integration of information system | acewriters
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1.What makes “integration” of information systems
so important to the success of Partners Healthcare (hint: consider the three
levels of information use – to transaction, to manage and control, and to
innovate) and how does information system integration across the enterprise
serve Partner’s use of business analytics to achieve its objectives?
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INTRODUCTION
According to government sources, U.S. expenditures on health care in 2009 reached nearly $2.4 trillion
(expected to reach $2.7 trillion in 2010).1 Despite this vaunting national level of expenditure on medical
treatment, death rates due to preventable errors in the delivery of health services rose to approximately
98,000 deaths in 2009.2 To address the dual challenges of cost control and quality improvement, some
have
argued that the U.S. health care system needs an integrated electronic medical record (EMR) system and
associated information technology-enabled processes.3 Although the information systems currently
available may meet the needs of the industry, the question remains regarding the requirements both
within
and by the health care services organization to achieve a satisfactory response to these dual challenges.
Partners Healthcare System (PHS) maintained a centralized digital records library on more than 4.6
million patients, augmented in real time by data, textual comments and artifacts (i.e. X-rays, MRIs
[magnetic
resonance imagings], EKGs [electrocardiograms], etc.) as these patients visited doctor offices, received
hospital-based or home care services, and obtained prescription medications and other therapies.
Procedures were in place to ensure the data quality and integrity of these patient files. Going forward,
any health care professional across the network could access a patient’s complete record, ensuring
accurate, timely and comprehensive information sharing about that patient’s medical history, allergies,
current treatments and other related information. In and of itself, the investment in this electronic
medical records
(EMR) system was expected to reduce delays in service delivery, mistakes in treating the patient and
overall health care costs. When coupled with a computerized patient order entry (CPOE) system to
inform the selection of drugs and appropriate treatment, PHS health care professionals were now
positioned to
target more specific therapies for their patients, to identify the most effective, low-cost options among
potential treatment strategies and to draw on a vast body of experience-based knowledge across the
network to inform patient care.
BACKGROUND: THE CHALLENGES FACING THE HEALTH CARE INDUSTRY
U.S. expenditures on health care in 2008 exceeded $2 trillion. Of that amount, approximately $747
billion
was spent on hospital services, $502 billion on physician and clinical services, $199 billion on nursing
home and home health care services, and $247 billion on prescription drugs.4 The cost of health care
was
expected to spiral even further out of control as the 1950s baby-boomer population became elderly.
Alongside the growing furor over escalating costs, the health care industry also faced persistent
questions
about the quality of the services it provided. Although the quality debate had persisted for some time,5
recent studies estimated that preventable medical errors led to as many as 98,000 deaths per year in
the
United States,6 clearly suggesting that better informed and more knowledgeable health care practices
could
not only save money for the government, insurance companies and individual-paying patients but could
also save lives.
In its most recent and comprehensive statement to date on the need to transform health care delivery
in the
United States through better information management, a study sponsored by the National Academy of
Sciences observed:
Health care is an information- and knowledge-intensive enterprise. In the future, health
care providers will need to rely increasingly on information technology (IT) to acquire,
manage, analyze, and disseminate health care information and knowledge. Many studies
have identified deficiencies in the current health care system, including inadequate care,
superfluous or incorrect care, immense inefficiencies and hence high costs, and inequities
in access to care. In response, federal policy makers have tended to focus on the creation
and interchange of electronic health information and the use of IT as critical infrastructural
improvements whose deployments help to address some (but by no means all) of these
deficiencies.7
The authors of this report determined that the crisis in health care delivery was not just a matter of the
cost
of these services but also a matter of quality.8 Even within the typical medical practice or hospital,
information about the patient was not integrated nor was it effectively leveraged to prescribe costeffective therapies.
Over the last two decades, a growing consensus has emerged that health care institutions fail to deliver
the
“most [cost] effective care and suffer substantially as a result of medical errors.” The National Academy
of
Sciences study observed that:
These persistent problems do not reflect incompetence on the part of health care
professionals — rather, they are a consequence of the inherent intellectual complexity of
health care taken as a whole and a medical care environment that has not been adequately
structured to help clinicians avoid mistakes or to systematically improve their decision
making and practice. Administrative and organizational fragmentation, together with
complex, distributed, and unclear authority and responsibility, further complicates the
health care environment.9
The current state of health care industry performance could be considered from both a cost and quality
standpoint, as a consequence of three sets of intersecting factors:
1. First, the nature of health care decisions were fraught with uncertainty about the patient’s current
state
of health and past medical history, the patient’s genetic predisposition (or lack thereof) to particular
medical therapies and the actual effectiveness of past and future treatments for that particular patient.
2. Second, the economic structure of health care delivery in the United States was extremely complex
and
could be argued to be counter-intuitive to the encouragement of low-cost options. Instead, the system
actively encouraged high-cost procedures under the guise of promoting risk-avoiding, “better”
medicine.
3. Third and finally, the very information systems and standards that could afford better integrated
service delivery, the identification of lower-cost medical options and the avoidance of mistakes in the
prescription of medications and other therapies were implemented in such ways as to throw up
significant barriers to information sharing and data-driven decision support.10
Despite the many very real barriers to the improvement of health care services delivery, the U.S. Federal
government, health care services organizations, medical practitioners, health insurance companies and
information technology companies that serviced this industry were coming together to help address
these
concerns. This effort required a significant investment of resources over an extended period of time,
perhaps a decade or more.11 Major U.S. research hospitals and their affiliated service delivery arms
were
transforming health care delivery in ways that could serve as a blueprint for industry-wide change.
Among
these institutions, Partners HealthCare System (PHS) illustrated the potential opportunities and the
ongoing
challenges in achieving more integrated, higher-quality and less expensive health care services delivery.
AN INTRODUCTION TO PARTNERS HEALTHCARE SYSTEM (PHS)
Partners HealthCare (PHS) was founded in 1994 by the partnering of Brigham and Women’s Hospital and
Massachusetts General Hospital to become an integrated health care delivery system that offered
patients a
continuum of coordinated high-quality care. As of 2009, the system included 6,300 primary care and
specialty physicians; 11 hospitals, including its two founding academic medical centers, specialty
facilities,
community health centers and other health care-related entities; and an ongoing affiliation with Harvard
Medical School. In 2008, Partners HealthCare serviced approximately 2.9 million outpatient visits and
149,000 hospital admissions. Its facilities at that time included 3,500 licensed hospital beds, serviced by
40,000 full-time equivalent (FTE) employees across its network of affiliates. For fiscal year 2008, PHS
generated more than $7 billion in revenue and conducted approximately $1 billion worth of biomedical
research. PHS also pursued joint ventures with the Center for Integration of Medicine and Innovative
Technology, Dana-Farber/Partners CancerCare, the Harvard Clinical Research Institute and The Partners
Center for Personalized Genetic Medicine (see Exhibit 1 for an overview of the PHS organization).
Over the years, PHS had come to exemplify the large, complex, successful and highly regarded
metropolitan health care provider, closely linked with academic medicine and medical research. Its
affiliation with Harvard Medical School and its exploration of leading-edge medical practices garnered
PHS substantial federal and private medical industry funding to support a rich portfolio of research
projects. PHS held information on more than 4.6 million patients, augmenting these records in 2009
through 2.9 million office visits, 149,000 hospital stays and the processing of 20 million prescription drug
orders.
From its inception, Partners focused both on keeping the costs of its services under control and
continuously improving the quality of service delivery and overall patient outcomes. To this end, the
organization’s leadership extended the electronic medical record integration achieved at both the
Brigham
and Women’s Hospital and Massachusetts General Hospital across its entire network. This investment
improved the quality of decision making both by individual doctors and medical teams concerning
prescription drugs and other medical therapies. It also leveraged medical practice knowledge to improve
the preventive and therapeutic treatments that the PHS network offered its patients. These aggressive
efforts to improve the quality, safety and efficiency of care were the centerpiece of the so-called “High
Performance Medicine Initiative” at PHS, which concluded in 2009. In reviewing the serious and
capitalintensive
efforts made by PHS on all of these fronts, Dr. James J. Mongan, president and chief executive
officer of Partners HealthCare observed:
Partners HealthCare is playing a leadership role in each area, and in fact, Partners is
demonstrating how organized systems can lead to solutions. Only organized systems — as
opposed to the very fragmented, disorganized non-systems that make up much of
American medicine — only organized systems can implement reimbursement reform,
thoroughly disseminate electronic medical records, and establish sophisticated disease
management programs.12
AN INTRODUCTION TO PARTNERS HEALTHCARE SYSTEM’S INFORMATION SYSTEMS (IS)
ORGANIZATION
PHS maintained a substantial information management arm. The 2009 Information Systems (IS) team
comprised 1,500 employees operating out of 19 locations in the greater Boston metropolitan area. With
an
operating budget of $196 million in fiscal year 2009 and a capital budget of $68 million, IS supported
80,000 end-users and 82,000 networked computer devices running in 140 PHS locations. In an average
month in 2009, the IS organization answered 18,000 calls; and over the course of 2009, it managed 250
major information technology (IT) projects for the enterprise. To realize its information management
objectives, PHS had invested heavily in information technology over the years and had hired some of the
best information management professionals in the industry.
John Glaser, the chief information officer (CIO) at PHS, had served in the same capacity at Brigham and
Women’s Hospital prior to the establishment of PHS. His first hire was Mary Finlay, who later became his
deputy CIO. Together they had served PHS since its inception, focusing on a strategic approach toward IS
unit staffing, planning and research, and the deployment of an overall IT architecture across the greater
PHS organization of end-users. Key personnel across the IS unit had, in addition to medical credentials,
either IT or business management credentials. Among the distinguishing features of the PHS Information
Systems organization were the following:
_ Stability in executive management and consistency in the articulation and pursuit of a common
strategic vision for the role of IT within PHS.
_ Top-flight talent recruited and retained in key positions across the organization.
_ The placement of executive level (i.e. CIO) positions within major business units to ensure an ongoing
C-level presence and thus alignment of IT within the business.
_ The development, adoption and maintenance of an enterprise-level architectural approach to IT
selection and acquisition.
Given the intense and in some ways unique use of IT in the various member hospitals and medical
services
units of PHS, each major business unit had its own customer-facing CIO, including Partners Community
Healthcare, Inc., which supported the 6,000-plus general and specialist physician groups affiliated with
PHS’s constellation of hospitals. John Glaser’s intent was to ensure that each key business unit within
PHS
had a strong IS advocate to focus on the particular information systems and technology needs of that
constituency’s health care practitioners (see Exhibit 2 for an overview of the PHS IS organization). As
part
of IS’ commitment to research and development (R&D), Glaser commissioned organizational units to
investigate the IT-enablement of core PHS business processes, including the following:
_ Clinical Informatics Research and Development to address clinical informatics infrastructure
_ The Center for Information Technology Leadership at Partners, which explored the return on
investment when purchasing an EMR or other health care information technologies
_ The Center for Connected Health, which considered how developments in IT and telecommunications
could transform health care delivery modalities
_ I2B2/National Center for Biomedical Computing, which studied the genetic similarities among cohorts
of PHS patients that reflected a particular respond to prescribed medical therapies
_ Clinical and Quality Analysis, which explored the impact of the PHS EMR and CPOE systems on care
delivery
PHS recognized early on that to be successful in these regards, three information management
capabilities
were required:
1. The means to collect and consolidate into an integrated digital record all the information about a
given
patient over time, including medical data, such as age, weight, height and vital signs; textual
information, namely the transcribed comments of those health care professionals with whom the
patient had interacted; and objects, such as X-rays and MRI scans.
2. Decision support processes that support the medical practitioner in making the best
recommendations
for drugs and other therapies on the basis of their likely benefits (i.e. positive outcomes) to the patient
at the lowest possible cost.
3. Knowledge management processes that derive best practices from the observable outcomes of
recommended medical therapies and employ these lessons learned to inform the ongoing delivery of
services and the reform of existing therapies.
PHS’s medical and IS leadership saw the company’s investment in IT as the enabling information system
foundation to achieve these capabilities.
PHS’S FORAY INTO ELECTRONIC MEDICAL RECORDS (EMR) AND COMPUTERIZED PATIENT
ORDER ENTRY (CPOE)
The founding members of Partners HealthCare, Brigham and Women’s Hospital and Massachusetts
General Hospital. pioneered electronic medical records (EMR) solutions. Massachusetts General Hospital
began work on an early version of an EMR system in 1976, and Brigham and Women’s Hospital initiated
an EMR in 1989. When these hospitals combined to form PHS in 1994, they adopted an internally
developed EMR platform, which they dubbed the Longitudinal Medical Record (LMR). Thereafter, as the
PHS network grew, member hospitals adopted LMR for their use in managing their digitized patient
records.
The operational requirements faced by PHS member institutions in this regard were two-fold. On the
one hand, each institution was obliged to establish processes to capture all ongoing health care
information
digitally and to convert past paper-based medical records to a shareable digital format. On the other
hand, due to the increasing interaction among members of the PHS services network, patient
information residing anywhere within the network needed to be made available to all PHS service
providers.
To address these requirements, PHS business units underwent significant process changes, and the
enterprise as a whole adopted an information management and technology architecture and platform
that proved flexible enough to deal with the differences posed by the various information systems and
digital record formats extant within PHS. Key among these innovations was the adoption and
widespread use of a
computerized patient order entry (CPOE) system that captured patient prescriptions and other physician
assigned medical therapies.
Although these efforts were not without their difficulties, they paled in comparison to the challenges
posed by bringing the 6,000 medical practitioners under the PHS LMR/CPOE umbrella. The barriers to
adoption included the following:
1. Two-thirds of the doctors in question had some formal affiliation with a PHS hospital, whereas the
rest were scattered around the greater Boston metropolitan area and operated out of their own local
offices.
2. Of those doctors with a formal affiliation with a PHS hospital, many employed an out-of-hospital
office or offices as their primary venue for meeting with patients.
3. Local doctors’ offices typically lacked the information technology and telecommunications
infrastructures to support the LMR and CPOE systems. System training and support were also issues,
especially when these tasks took time away from either seeing patients or keeping abreast of
developments in a specialized field.
4. Many of these health care practitioners, though perhaps not technophobic, were not enamored of
interacting with a computer terminal while they were seeing a patient and were even less interested in
using a computer system for taking notes and issuing prescriptions when handwritten work was
perceived as more efficient, easier and less stressful.
5. The cost of implementing an LMR/CPOE connection in a physician’s office cost an average of
$40,000 per doctor. Existing anti-kickback legislation prevented PHS from subsidizing the adoption of
this information management platform.
The move to bring all PHS medical practitioners under the same medical information management
umbrella got underway in 2002/03. The rollout was characterized by a three-pronged deployment
strategy:
1. A focus on a value-added experience for the doctor, moving beyond the capture of insurance claims
processing data and toward content delivered through the system to help the physician to better
diagnose the patient and to recommend the most cost-effective therapies.
2. A focus on system ergonomics and usability, for example, to speed the process of patient data
capture and to more readily identify recommended therapies, drug allergies and other related data.
3. A focus on early opportunities for immediate and dramatic success in the implementation and rollout
of the system to particular doctor groups married with an ongoing, incremental process of deployment
that targets those most open to the change.
Key to the realization of this strategy was broad community involvement through a multi-tiered
approach to involve key hospital organization and medical practitioner stakeholders in project
governance. To that
end, PHS executive management engaged existing committees and working groups while establishing
new ones as needed, inclu …
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