Monday, February 18, 2008

Electronic Health Records for Non-owned Doctors - Planning for Distributed Users

This is the fourth entry in my series about electronic health records for non-owned doctors. Today's topic is about supporting hundreds of clinicians, spread over a wide geographical area with varying levels of IT infrastructure and technology savvy.

CIOs of academic healthcare facilities are used to highly controlled and predictable environments. We oversee the quality of service from end to end. Desktops have a managed image with updated anti-virus software. The network is physically secured in closets we control, using fiber and cables we install. Our teams and our management is optimized to deliver service that are consistent and standardized.

The Electronic Health Record project for non-owned doctors requires a different approach. The initial 300 doctors in 173 physical locations spread over 450 square miles have diverse needs and heterogenous access to infrastructure. Some already have computers, wired and wireless networks. Most do not. Those in rural areas may have limited access to bandwidth, making business DSL their only choice for connectivity.

The alternatives we considered for serving these geographically distributed users was

- Expand our current IS offsite team which currently focuses on BIDMC owned clinicians and those occupying BIDMC leased space. This matrix illustrates the different kinds of physicians we support and the services we currently provide.

- Negotiate group purchasing agreements with vendors and make these available to clinicians, reducing heterogeneity but not providing installation and management of the infrastructure. Physicans could hire local consultants, family members, or do it themselves.

- Outsource the infrastructure of these practices to a firm specializing in managing the IT needs of independent clinicians

We weighed the benefits and costs of each approach and elected to outsource infrastructure to Concordant.

Here's our thinking

-Geographically distributed practices needing 24x7 support would require a large internal team to provide a high service level, weekend coverage and vacation coverage. Although we are currently planning on 300 clinicians, that number might expand to 500 or 1000, hence scaling up with agility would be challenging, especially in a job market where many hospitals are competing for skilled IT professionals.

-Our current offsite group is extremely good and focused on providing infrastructure and application services to sites we operate. Expanding this group to support a very different kind of practice with very different infrastructure would dilute their current focus.

-Enabling these distributed offices to purchase their own equipment and establish their own local infrastructure could be disastrous. Guaranteeing service levels means that we must have an understanding of the network performance, desktop configuration, and local infrastructure (printers, scanners, fax machines) of each office.

Our plan is to operate a highly reliable hosted electronic health record, housed a commercial co-location facility and make it available to each of these practices via the public internet without having to create network or telecom connections ourselves. At each office location, however, the desktops, wired and wireless network will be completely homogeneous and managed by Concordant. We'll leverage the scale of the project to obtain the best discounts possible from hardware vendors. We'll even retire existing office hardware to achieve homogeneity. Help desk services will be staffed by Concordant, so that we will not need to train our existing help desk staff to support these distributed non-owned clinicians.

We elected not to place servers in any clinician offices since physician offices do not have backup power, environmentally controlled server rooms, or appropriate physical security for machines hosting the data. Our plan is to maintain a central hardware depot, assemble all the equipment needed for an office, deliver it, configure and test it. Everyone wants to minimize on-site support, but some on-site service will still be needed for hardware failures and very "high-touch" support. Remote support and monitoring techniques can help, though minimally, since we're implementing a centralized architecture.

It is our hope that a dedicated outsourced infrastructure service, optimized for the needs of the geographically distributed small physician office will work better and cost less than expanding our existing IS teams or enabling physicians to do it themselves. It also enables us to track costs more closely since there is a strict separation between support for owned sites and non-owned sites. Our first non-owned sites go live in June and I'll let you know how it goes.


Richard Dale said...

This is a great series - thanks. My question is whether these non-owned practices have relationships with other networks and so have a choice (or worse, a multiplicity) of EMRs? If so, how does it work out? Also, you describe providing some consistency with a single set of hardware and a particular service provider... How does that work if the practice has other systems (for management/billing etc)?

John Halamka said...

There is no choice of EMR - we're implementing eClinicalWorks. This is the only way to achieve clinical integration and quality measures needed for pay for performance. Similiarly, we're mandating one practice management system, the one built into eClinicalWorks. Creating numerous interfaces to heterogeneous practice management systems is a recipe for disaster.

Richard Dale said...

I think this answers my question - these non-owned offices do not have relationships with other hospitals (Childrens or Partners) or utilize services (and SaaS s/w) from folks like AthenaHealth?
Will adoption of your PPM/EMR be a requirement in future for practices who wish to maintain their relationship with BIDMC, say if they currently use AthenaHealth for their PPM? Alternatively could you imagine a practice with their own EMR inter-operating through a RHIO infrastructure?
(Excuse these questions - I am not so familiar with the relationships between non-owned practices and the hospital.)

Steve Waters said...

Semper Vivo,, is able to provide choices for EMR and PMM. The service is designed to integrate across different systems and eliminates the need for small medical practices to buy server hardware and software while eliminating the lions share of consulting costs. Local hospitals are not equipped to provide these services and this is clearly an area where RHIO's and HIE's are unable to develop sustainable business models. The fact is it is very difficult to determine exactly which way medical records are likely to go particularly when you throw in Personal Health Records as proposed by Microsoft and Google. Therefore an adaptive solution is a very good choice for any provider looking at implementing medical software and technology into their practice.

StephSup said...

Its so awesome that you have this blog. I'm an IS major hoping to go into Heath IT, this blog kinda helps me see what's going on in the field a little bit; even though half the time im confused, but it's all good, im learning slowly.. keep posting :)