Tuesday, April 29, 2008

Integrating the Electronic Record

This is the third blog in my series of 2008-2009 areas of personal focus - clinical documentation, decision support, and the integrated electronic record .

At BIDMC, we buy and we build applications. We've purchased vendor systems for Lab, PACS, anesthesia documentation, ICU charting, and cardiology data management. We've built our electronic health record, provider order entry and our portals, which means that we create the enterprise front ends used by clinicians. All our home built applications share one fully integrated database. However, we must integrate data from dozens of vendor applications with our home built applications, which we've done via a service oriented architecture. Further, we have to integrate data from multiple outside organizations to reconcile medications and ensure continuity of care. Our strategy is to converge all viewing, ordering, documentation, and sign on to a single application - our self built electronic health record called webOMR. Of course, some departments such as the lab will use purchased applications such as the laboratory system for their internal departmental workflow, but the clinicians will never know that we have a purchased lab system, since all their work will be done via webOMR. Here are the top 40 ways we integrate data among our various applications.

1. WebOMR displays laboratory and radiology results from our community hospitals - Beth Israel Deaconess Needham, Mt. Auburn, and New England Baptist using real time integration from Meditech via a service oriented architecture.
2. WebOMR supports full ambulatory order entry with automated electronic routing of radiology, cardiology and laboratory for our affiliated community hospital, BID Needham.
3. WebOMR will soon display an indicator on the patient summary if community hospital data is available for viewing, reminding clinicians to look for these external results.
4. WebOMR includes viewing of all endoscopy reports and photos from our Gcare endoscopy system.
5. WebOMR includes viewing of all echocardiology reports from our Encor echo reporting system.
6. We've built a 'popup' version of WebOMR for eClinicalWorks and CareTracker users, so private clinicians in the community can view all BIDMC data on their patients without having to leave their office EHR.
7. We've also included ordering of BIDMC labs and radiology diagnostics within the 'popup' version.
8. WebOMR displays all problems, medications, allergies, visits, notes/reports, and labs from the Joslin clinic, an affiliated but separate institution.
9. WebOMR includes viewing of allRadiology images from GE Centricity PACS.
10. WebOMR includes viewing of Radiation Oncology Reports from Impac.
11. WebOMR includes viewing of Electrophysiology Reports from GE Cardiology applications.
12. WebOMR includes viewing of Anesthesia flow sheets from Philips Compurecord.
13. WebOMR will include viewing of IMDSoft ICU Charting later this year.
14. WebOMR will include Enterprise Image viewing of all non-radiology imaging modalities by next year.
15. WebOMR will include viewing of scanned inpatient papers records by June 2008.
16. WebOMR includes integration of pediatric immunization records from our community health centers.
17. WebOMR displays inpatient discharge meds from Provider Order Entry and offers one click conversion of inpatient medications to outpatient medications.
18. WebOMR includes full e-prescribing integration to our statewide eRx Gateway including eligibility checking, formulary enforcement, routing to retail and mail order pharmacies, and community-wide medication history with drug/drug and drug/allergy checking.
19. WebOMR pushes discharge summaries to community clinicians via our statewide Clinical Data Exchange Gateway.
20. WebOMR offers a single point of entry to all other systems including all inpatient functions such as POE. Single signon enables clinicians to logon once to use all functions.
21. Webomr and Provider Order Entry share and exchange data such as immunizations, allergies, and health care proxies. Our Perioperative Management System (OR Management) also shares allergies and health care proxies.
22. Our Cardiology systems consolidation (planned for 2009-2010) will include full webOMR viewing of cardiology data.
23. Inpatient documentation including Medication reconciliation, History and Physicals, Sign out/Team Census enhancements, and Discharge enhancements planned for 2009-2010 will ensure that all inpatient documentation is available elecronically in webOMR.
24. Our transplant record will soon be fully integrated into webOMR
25. Our Perioperative Information Management system offers fully integrated OR workflow management. We are planning PACU documentation and its integration with ICU documentation now.
26. Our ED Dashboard offers fully integrated viewing of all outpatient and inpatient data about the patient in one place
27. Our Oncology Management System offers fully integrated Heme/ONC Management incorporating all lab, medication and history data for both outpatient and inpatient settings in webOMR.
28. Our Radiology Portal offers fully integrated radiology services supporting key clinical, quality assurance, and administrative workflow functions in one place.
29. Antibiotic precautions (e.g., MRSA, VRE) are displayed in our admitting and outpatient scheduling systems.
30. Perioperative Information Management, Appointment Scheduling and Admitting all share information to eliminate duplicate data entry as an operating room case and its associated admission and pre-admission testing appointment are scheduled.
31. Appointment scheduling integration with webOMR includes printing the webOMR med list at appointment check in, prompts for diabetic ophthalmology screens in scheduling, reports of missing and unsigned notes within scheduling, and webOMR display of recent and future appointments.
32. Admitting/Emergency Department integration with webOMR includes displaying recent Emergency Department and inpatient visits.
33. Registration integration with webOMR includes displaying insurance summary, Medicare D coverage, and medication assistance counseling alerts to assist with prescribing in webOMR.
34. Our physician billing application, ETicket, automatically adds patients to providers’ censuses for operating room cases after patients are entered into the Perioperative Information Management System.
35. ETicket automatically adds patients to providers’ censuses after encounters in Labor and Delivery Triage and OB/Gyn triage.
36. All our electronic payer transactions for eligibility, referral/authorization, claims, and remittance are fully integrated into our scheduling, registration and billing systems.
37. Our capacity Dashboard integrates real time utilization data from admitting, Emergency Department, Provider Order Entry, Cath Lab, Transfer Log, and ICU Callout systems.
38. Our Diabetes Registry incorporates data from BIDMC and Joslin to facilitate comprehensive, integrated reporting on diabetic care
39. We maintain data marts for a broad range of clinical systems, including laboratory, microbiology, blood bank, radiology, inpatient pharmacy, outpatient medications, OR, and demographics, admitting and scheduling. These support data mining, research, and quality/performance measurement within and across systems.
40. A web page that tracks the health of all this integration runs 7x24 in our command center, refreshing itself every minute. In addition to monitoring many different infrastructure level parameters, this caretaker also checks on various applications, including integration engine feeds, Medquist (dictation) transactions, and various Emergency Department functions.

From the list above, I hope I've illustrated that interoperability between systems at BIDMC includes human readable data exchange, semantic interoperability for decision support, and process interoperability, linking workflow among various systems.

With this degree of data integration, we're approaching the tipping point which will enable us to transition from a hybird paper/electronic record to a fully electronic record and we have a retreat this Summer to plan for that transition and adjust our governance as needed.

Will we ever be done with 100% integration of every element of data from purchased and built systems? No, but the journey moves fast enough to keep the patients safe and the clinicians satisfied.


Johnnysmooth said...

Once again John, a fascinating post on all the systems that you and your team are tying together to facilitate the "digital hospital."

But of those 40 items listed, no where did I find any mention of how security and privacy will be addressed within the confines of this system. For example, can I as a patient of BIDMC be able to define who can and can not see my records? Am I able to sequester certain aspects of my record to be shared with only a discrete care team and not every nurse and doc in the network? To what level of granularity can I have my data tagged to enable such privacy? And once you have all this beautiful technology in place, how will you share it with say your brethren across the street should I have an accident and end up in the ED of BWH?

As an aside, interesting article today in the WSJ, last section of security of digital health records.

Unknown said...

I would be curious to know if you would share what database platform is used for WebOMR.


John Halamka said...

Regarding the first question, my Blog next Tuesday will describe in detail, the role-based access control we use to protect the record.

The database underlying webOMR is Cache, but importantly, it's the web services architecture which enables us to connect to multiple external data sources.

Johnnysmooth said...

Thanks John, look forward to seeing that post next Tue and will reference it in a future post on Chilmark Research site

Norma said...

What have you done in Labor and Delivery? Is the outpatient prenatal record incorporated into the labor and delivery record? How are the fetal heart rate tracings incorporated?

Jenel Farrell said...

Hi. I'm a digital archivist. I'm curious about the electronic records used in medical environments and wonder if there's a possibility of a universal system? I can easily imagine the complications, but is a topic of interest currently in the library and archiving communities.