Interoperability and Actionable Intelligence: Future Requirements, Current Possibilities
January/February 2011
Interoperability and Actionable Intelligence: Future Requirements, Current Possibilities
Government requirements for “meaningful use” of electronic health records (EHRs) have focused national attention on the need to integrate and computerize a patient’s medical records to improve performance and support patient care processes. The Centers for Medicare and Medicaid Services (CMS) have set forth three stages of hospital requirements and financial incentives for 2011, 2013, and 2015, with disincentives not far behind (CMS, 2010).
Interoperability—the ability of diverse information technology (IT) systems and medical devices to inter-operate (work together)—originally was part of CMS’s hospital requirements for Stage 3, but some components could be advanced into the Stage 2 requirements for 2013, which have not yet been finalized. The ability to automatically collect and integrate patient-related data and to present that data when, where, and how it is needed—not only for clinicians but also for management—can help hospitals measurably improve patient safety and care, reduce costs, and optimize productivity now.
This article includes a brief review of the current state of hospitals’ transition from paper-based to digital records, how “interoperability” differs from “connectivity,” current examples of the benefits of interoperability and next steps to help hospitals maximize the benefits and ease the pain of transitioning from paper-based to computerized healthcare.
Current State
As of September 2010, only 1% of hospitals had a complete EMR. About 50% had clinical documentation, mostly used by nursing (HIMSS Analytics, 2010). In the vast majority of hospitals, the healthcare environment is crowded with disparate, self-contained devices, technologies, and IT systems that do not communicate with each other.
Without electronic documentation, clinicians manually enter all or part of a patient’s information into a medical record, usually paper-based, greatly increasing the possibility of error. In many cases even information from electronic medical devices is entered into the medical record manually, increasing clinicians’ workload and introducing yet another source of error. Without the electronic integration of all patient-related data, critical information is not available when and where it is needed, leading to less than optimal treatment, time-consuming duplication in workflow, financial loss, and noncompliance with regulatory guidelines. Thus, interoperability offers the greatest opportunities for hospitals to improve accuracy, productivity, cost-savings, and quality of care.
Connectivity ? Interoperability
Interoperability goes beyond connectivity to allow devices and systems to interact and affect each other’s function. Some devices have one-way connectivity; few, bidirectional connectivity; a very, very few have achieved interoperability.
- One-way connectivity: exports data from a medical device into a clinical information system (CIS)/EMR. This is the most basic and least valuable capability, and has been available for years.
- Bi-directional connectivity: uses a standard format to export data from a medical device into CIS and import data from CIS into the device.
- Interoperability: allows intelligent medical devices to “talk” among each other, as well as to connect with the CIS. Actionable data from one medical device can affect the behavior of another device or system. Actionable intelligence is available when and where needed for caregivers and hospital leadership. Medical devices and CIS/EMR act together, providing a single, more reliable source for pertinent patient information.
Achieving interoperability between a medical device and a clinical information system is far more challenging than creating a uni-directional interface. In particular, the design and implementation of a high-reliability, high-quality system to collect and integrate patient-related information must take into account the system’s impact on clinical workflow.
Clinician and Management Decision Support
Interoperable systems and medical devices collect and aggregate transactional data automatically. Performance analytics using data mining and artificial intelligence turn those data into actionable information, such as key performance indicators and return on investment (ROI) metrics. The information can provide insights on the past, details on the present, and forecasts for the future, which hospitals can use to improve safety, cost, productivity, and compliance.
Decision-making by clinicians and management is better supported by having enterprise-wide, actionable information that otherwise would be labor-intensive and time-consuming—if not impossible—to obtain. For example, alerts are delivered to clinicians in real time for proactive therapy adjustments and the information is aggregated to use for long-term ADE management. Managers no longer have to spend hours working through reams of paper and instead can use that time to focus on improving patient care and productivity.
Current Examples of Interoperability
The following examples illustrate the benefits of interoperability for clinicians and/or management:
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Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. Electronic health records (EHRs) are built to share information with other healthcare providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.” With fully functional EHRs, all members of the team have ready access to the latest information, allowing for more coordinated, patient-centered care. (Garrett & Seidman, 2011) |
Laboratory data displayed on automated dispensing machine (ADM) screen. When ADMs are linked with a hospital’s laboratory information system, up-to-the-moment laboratory data can be configured to display on an ADM display screen at the time a nurse goes to withdraw a specific medication from the ADM. For example, a change in a patient’s partial prothrombin time (PPT) could indicate the need for the pharmacist or physician to evaluate the patient’s heparin dosage prior to proceeding with administration. Having such data available exactly when and where needed helps improve quality of care, nursing workflow, and productivity.
Integrating patient-controlled analgesia (PCA) with respiratory monitoring to automatically pause high-risk infusion. In patients using PCA, respiratory status can change rapidly, and even young, otherwise healthy patients are at risk of opioid-related respiratory depression (APSF, 2006). Now patients using PCA can be automatically monitored for respiratory changes: for example, by using non-invasive capnography to measure end-tidal carbon dioxide (EtCO2) levels and respiratory rate. If hospital-defined monitoring parameters for opioid-related respiratory distress are exceeded (for example, carbon dioxide levels are too high and/or respiratory rate too low), interoperability between the respiratory monitor and the PCA pump can automatically stop the infusion of pain medication.
Operating room case-costing efficiency. Hospitals can help streamline workflow and increase productivity by deploying interoperability between automated supply cabinets and a hospital’s admissions/discharge/transfer (ADT), materials management information (MMIS), billing, and operating room information systems (ORIS). Linking automated inventory management, clinical charting, revenue cycle management, and implant documentation helps ensure that clinicians obtain the correct supplies needed by the surgeon, allowing cases to start on time. This process also reduces unnecessary trips in and out of the operating room and allows clinicians more time to focus on patient care. Withdrawing the supply items from the ADM automatically charts supply-usage information directly into the patient record and also automatically charges for and reorders that item with just the touch of a button, reducing clinical documentation time and error. This type of interoperability allowed a 197-bed community hospital to reduce clinical documentation time by more than 10 minutes per case. (CareFusion, 2009.)
Drug diversion. ADM medication management analytics software can also help hospital pharmacists to closely examine patterns of controlled-substance use, identify signs of diversion, and take action by tracking discrepancies, controlled-substance removals, and cancelled transactions. Nursing unit managers can deep dive on information down to the user, and executives, who might need a higher-level view of information, can review an executive summary.
Antimicrobial stewardship and infection control monitoring. Automated surveillance and analytics support antibiotic stewardship, including IV to PO programs and drive better understanding of where errors are occurring. Antibiotic stewardship, including the use of proactive alerts for lower spectrum therapy, has been shown to reduce drug cost 22% (Carling et al., 2003).
Advanced ADE and HAI surveillance capabilities can pull information from a hospital’s laboratory, PhIS, ADM, ADT, and billing systems and use evidence-based rules to measure infection rates and monitor patients for potential adverse drug events (ADEs). Automated surveillance using interoperable systems has been shown to help hospitals reduce the rate of HAIs by an average of 13% (CareFusion & MedMined, 2010).
Inventory/supply chain management. Knowing which medications are used in which areas can help management to optimize ADM configuration and stocking, reducing stock-outs, making work more efficient for nurses, and reducing costs through improved inventory control. Closed-loop medication management makes it possible to track medications from receiving dock to point of care, automatically document every step, monitor usage, and reorder. This helps reduce inventory costs, increase productivity, and free staff to focus on patient care.
Next Steps for Hospitals
Achieving interoperability
As a first step, hospitals and integrated delivery networks must have a clear vision of the goals and future state they want to achieve. Once goals have been established, the next step is to form multidisciplinary teams involving all stakeholders to focus on achieving interoperability and meeting meaningful use requirements. Facilities must do advance planning on infrastructure and optimize existing work processes. A wireless infrastructure is critical and must be carefully planned and implemented. Additionally, a facility’s wired network must be assessed for its ability to manage the desired future state. Having a robust integration engine to connect advanced medical devices and support all the interoperable components is also critically important.
Meeting requirements for EMR meaningful use
As pointed out in HIMSS News (Hoyt, 2010), hospitals need to determine whether your existing vendor can meet the 2011 and 2013 measurements within the timeframes set for implementation and adoption of EMR applications in your facility. If your requirements cannot be met, you should institute replacement proceedings immediately (vendor/product evaluation and selection processes).
Conclusion
Interoperability of intelligent medical devices and IT systems will become even more important as the ability to automatically capture and manage patient data plays an increasing role in improving patient safety, clinical outcomes, staff productivity, and financial performance. Interoperability can also help improve financial performance by helping hospitals achieve the future requirements for meaningful use to receive Medicare and Medicaid incentive funds.
Kevin Ketzel is the national vice president for the Dispensing Technologies Business Unit at CareFusion Corporation. Ketzel has more than 18 years of healthcare information technology and medical technology management experience. Prior to joining CareFusion, Ketzel was the chief operating officer and general manager for Medware, a healthcare information technology company focused on medication and blood management systems. Ketzel has also worked in various leadership capacities for Cerner Corporation and Allscripts, both leaders in healthcare information technology.
David Swenson is vice president, marketing and product management for the Dispensing Business Unit at CareFusion Corporation and serves on the Clinical Advisory Board for MediPacs, Inc. Prior to joining CareFusion, he was co-founder and chief clinical officer for IntelliDOT Corporation, which recently transitioned to PatientSafe Solutions. Swenson’s background includes more than 17 years of hospital pharmacy and hospital pharmacy management experience. As one of the original product managers for Pyxis Corporation, he was responsible for the product design of the MedStation-Rx System, the first pharmacy profile-driven medication cabinet system. Swenson holds a BSc degree in pharmacy from the University of Washington and has completed master of business administration classes at City University in Seattle. He may be contacted at david.swenson@CareFusion.com.