Implementing an Effective Interoperable EHR System

Mrunal Shah, MD, ABFM, discussed his large integrated health system's experiences with implementing a system-wide electronic record.

During his educational session Tuesday morning at HIMSS, “Healthcare Interoperability: Achieving Meaningful Use and Beyond,” Mrunal Shah, MD, ABFM, vice president of Physician Technology and OhioHealth Information Services, discussed his large integrated health system’s experiences with implementing a system-wide electronic record. The number one question during the process, said Shah, was always “How do we create an environment to improve patient care?”

At the start of the process, in 2005, Shah said that OhioHealth knew they had a large amount of digital information already out there in their system (some physician offices had at that point already begun to implement EHRs in their offices), but the problem was that the data “stayed where it was in the system,” with no mechanism for exchanging data among the various providers.

Before an effective solution could be implemented, Shah’s organization had to answer a number of questions and concerns (a number of which are by now no doubt familiar to many providers and groups who have undergone their own implementation process):

Can we make sure we can “bring the data back?” In other words, can the EHR ensure that patients who contact multiple points of the health system are matched appropriately with their data? In other words, can you ensure you match the right data to the right patient 100% of the time.

How do you account for the concerns and needs of all stakeholders in the process? In Shah’s case, this included the reference lab and radiology, the marketing and communications team (being able to advertise that you have a way to connect with physicians can be a powerful recruiting tool); the operations team; the legal team (which wants to make sure the system provides physicians with information in as rapid and predictable manner as possible while simultaneously ensuring a safe environment for patient data); and the physician leadership (who will be the ones to articulate and explain the value of the EHR in this environment).

Will the system facilitate your ability to “bridge care” — will provider A be able to talk to provider B, who practices in another institution?

How will the EHR affect providers’ ability to manage medications safely and ensure that patients are not at increased risk due to poor communication and incompatible information sharing? How will the system guard against a case where a provider in an affiliated physician’s practice prescribes a medication that puts the patient at risk for drug-drug interactions because that provider didn’t know about medications that had been prescribed by another provider in the organization?

Shah said that the minimum digital requirements are an integrated EHR; the capability to electronically prescribe (“As the patient’s information grows, how you prescribe is an increasingly critical factor,” said Shah); clinical data repositories that keep data individual, discrete, and movable; online documentation tools; and robust interface technology.

Although the technical aspects of the implementation process are paramount, Shah pointed out that there are several additional drivers that cannot be ignored. First and foremost, he said, is that an organization must always design its processes to conform to a patient-centric care model. “Keep the patient in the middle, so that all information is anchored on that patient, said Shah. This is especially important in a large integrated health system because “providers tend to look at their environment as the center of care.” Another driver is the need to provide more information at the point of care. Shah emphasized at several points that you should “leave physicians in their space.” Don’t make ER docs leave the ER to find the information they need, for example. Don’t make physicians move from one tool to another to find the complete information picture; the more they have to move, the more barriers they will encounter.

According to Shah, OhioHealth pursued a successful “connectivity strategy” by offering their EHR to the community of practices (which they were able to do following modifications in the Stark laws), providing a standalone e-prescribing solution, and promoting data interoperability. All of this was done to increase patient safety by providing more point-of-care information, improve physician and staff satisfaction with more efficient processes (thereby improving uptake), and expand the network of care.

OhioHealth pursued a strategy of “hosted interoperability,” which Shah defined as a “black box” approach that allowed their system to talk to multiple providers operating on multiple platforms by transmitting data through a central data hub. The rationale for this is that it allowed OhioHealth to stay source and recipient agnostic, pursue an aggressive growth strategy with low capital and scalable operational costs, and achieve rapid deployment with little to no added resource requirements. To do this required a robust and longitudinal healthcare system clinical data repository and sophisticated interfacing technology (the black box approach outlined above).

While acknowledging that the implementation process had been long, complex, and fraught with several false starts and unforeseen difficulties, Shah said that initiating the process had been worth it for several reasons. If his organization had waited to follow the example of other groups and organizations, Shah said they would be unacceptably far behind at this point and would be operating at a competitive disadvantage, facing the prospect of spending even more money and having a shorter implementation window once all the remaining questions surrounding ARRA and HITECH are answered.

In closing, Shah reminded the audience that to ensure a successful implementation, they had to explore different budget options within their organization (especially under the current economic conditions), know and understand the needs of their stakeholders so they can align their project with cost savings and patient safety goals, build their business case by building on existing technologies to drive increased efficiencies, and evaluate the procurement options that are right for them (eg, deciding between SaaS vs. in-house hosting).