Session 13: Partners Case Study Questions 1. Create a table that lists the benefits to the patient and to the hospital of an enterprise system for patient medical information and a system for patient prescriptions and related medical therapies. Information System LMR Benefits to Patient Benefits to the Hospital add more rows as needed…. CPOE add more rows as needed…. 2. List the challenges faced by Partners in implementing an enterprise-wide electronic medical records system and the CPOE. a. . b. . c. . d. . e. . f. . g. add more lines as needed…. 3. What are the total cost of ownership (TCO) implications of the overall LMR/CPOE investment? a. . b. . c. . d. . e. add more lines as needed…. 4. Provide examples of how Partners can use the LMR and CPOE systems to enable transacting, managing and learning/innovating? The 3 Levels of Information Use transacting LMR CPOE management and control learning and innovation prepared by rmk 050714 Page 1 Session 13: Partners Case Study Questions prepared by rmk 050714 Page 2 Partners HealthCare System (PHS): Transforming Health Care Services Delivery through Information Management prepared for the CIRD Seminar by Richard M. Kesner, Executive Professor in MIS D’Amore-McKim School of Business Northeastern University Acknowledgements        John Glaser, CIO, Partners HealthCare Systems (PHS) Mary Finlay, Deputy CIO, PHS Steve Flammini, Chief Technology Officer, PHS Susanne E. Churchill, Executive Director of I2B2/National Center for Biomedical Computing, PHS Joseph C. Kvedar, Director, Center for Connected Health, PHS Blackford Middleton, Corporate Director, Clinical Informatics Research and Development, PHS Cindy Bero, CIO, Partners Community Healthcare, Inc. Note: While these good people contributed mightily to the quality of this case study and its companion teaching note, the author alone takes full responsibility for any errors of omission or commission found herein. prepared by rmk 081310 2 Motives Behind this Case Study:     the importance of the medical services/health care industry as part of the U.S. economy. the need for a greater focus on this industry as part of a general curriculum in management and business administration. the need for new/improved learning tools for management information system (MIS) students, especial concerning the healthcare industry. a personal interest in the healthcare industry and the role of decision support analytics and knowledge management in that industry. My recently published PHS case study and teaching note are a partial response to all of this. prepared by rmk 081310 3 Methods   met with John Glaser to define the scope of my initial inquiries interviewed: ◦ Cindy Bero ◦ Susanne E. Churchill ◦ Mary Finlay ◦ Steve Flammini ◦ John Glaser ◦ Joseph C. Kvedar ◦ Blackford Middleton    reviewed a wide range of published articles and PHS internal documents interacted with PHS as my work was reviewed and ultimately approved by PHS for publication currently exploring opportunities for follow-up research prepared by rmk 081310 4 Historical Context  U.S. expenditures on health care in 2009 reached nearly $2.4 trillion dollars ($2.7 trillion by the end of 2010) - Plunkett Research, Ltd., (2008). “U.S. Healthcare Industry Overview,” www.plunkettresearch.com/Industries/HealthCare/HealthCareStatistics  preventable errors in the delivery of health services rose to approximately 98,000 deaths in 2009 - Leape, Lucian L. and Berwick, Donald M. (2005). “Five Years After To Err Is Human: What Have We Learned?” Journal of the American Medical Association 293(19):2384-2390   the nation is currently engaged in a fierce debate as to how best to improve healthcare delivery while reducing its cost to patients and tax payers some have argued that an integrated electronic medical record (EMR) system and associated decision support systems like computerized patient order entry (CPOE) will enable both improved care and lower delivery costs- Stead, Willam W. and Lin, Herbert S., editors (2009). Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions (Washington, D.C.: National Academy of Sciences, National Academies Press prepared by rmk 081310 5 What PHS Has Done        1976 - Mass General begins work on an integrated electronic medical record system. 1989 - Brigham and Women’s initiated a similar effort. 1994 – Mass General and Brigham and Women’s join forces to form Partners Healthcare System (PHS) From its inception PHS committed itself to the universal use of ERMs and the leveraging of medical knowledge and best practices across its network of providers. 2002/3 - This led PHS to develop a common, more-robust EMR program, dubbed the Longitudinal Medical Record (LMR) as well as its own computerized patient order entry (CPOE) platform. 2007 – The PHS network achieve a 90% penetration rate with its LMR and CPOE systems. 2009 –100% participation in LMR and CPOE by PHS personnel. prepared by rmk 081310 6 Seven Critical Success Factors in the Implementation of LMR and CPOE ◦ a sound management framework: employ project management best practices, appropriately skilled personnel, and commonsense in the execution of the project. ◦ centrality of processes: focus on improving the enterprise’s core business processes. ◦ organizational partnerships: involve internal stakeholders throughout the life cycle of the project and ensure that these stakeholders are intimately engaged in major IT project governance. ◦ progressive incrementalism: break large undertakings into smaller, manageable components and proceed from one project phase to the next based upon positive outcomes, lessons learned and team readiness. Source: Glaser, John P. (2008). “Seven Durable Ideas,” Journal of the American Medical Informatics Association 15(3):267-71 prepared by rmk 081310 7 Seven Critical Success Factors in the Implementation of LMR and CPOE ◦ architecture:. build any important IT solution as part of an enterprise architected plan and stay true to your architecture. ◦ embedded research: as in my PHS Case Study, conduct the research necessary to understand the range of business and technological implications of the project’s activities and anticipated deliverables; develop, identify, and deploy best practices throughout the life cycle of the project. ◦ engage the field: communicate outside the enterprise with colleagues engaged in similar endeavors to cross-fertilize thinking and to incentivize personal staff development for the best possible outcomes. Source: Glaser, John P. (2008). “Seven durable Ideas,” Journal of the American Medical Informatics Association 15(3):267-71 prepared by rmk 081310 8 PHS Approach to LMR/CPOE Deployment  a sound management framework ◦ longer –term staffing strategy ◦ staff longevity ◦ highly credentialed ◦ focused on best practices  centrality of processes: ◦ project addressed the core processes of patient care and healthcare quality ◦ sponsorship at the highest levels within PHS ◦ project leadership by the enterprise CIO and his executive team ◦ strong liaisoned partnerships with established business, practitioner, and research groups across PHS  organizational partnerships: ◦ Council of Chief Medical Officers, Chief Nursing Officers and Chief Information Officers ◦ Physicians Executive Council ◦ Clinical Systems Operations Committee ◦ Architectural Council ◦ etc………………….. prepared by rmk 081310 9 PHS Approach to LMR/CPOE Deployment  progressive incrementalism: ◦ evolution of LMR and CPOE ◦ continuous improvement of products, user platform and systems integration ◦ rolled out in phases    early adopters mainstream users resistant users ◦ provision of an extensive training and support infrastructure ◦ financial incentives and disincentives (the latter for non-compliance)  architecture: Overview of a Service-Oriented Architecture Web-Based Portals Physicians, Nurses, Researchers, Administrators Applications Order Entry, Clinical Documentation, Order Processing Services Clinical Decision Support, Event Scheduler, Notification, CDR access Knowledge & Data Data Repositories, Controlled Medical Terminologies, Catalogues, Dictionaries and EMPI Infrastructure Data Center, User Devices, Networks, Security Provide customized access to relevant clinical applications and patient information based on end user roles and individual requirements. Aggregate services into logical components that support specific functions Re-useable software modules that address specific clinical IT capabilities Logic and tools that access data repositories for patient information, knowledge and terminology Technical foundation and support for clinical applications and end users prepared by rmk 081310 10 PHS Approach to LMR/CPOE Deployment  architecture: [continued] Physician's Portal Application Layer Services Layer Event Management and Orchestration Framework Portal Layer Nursing Portal Research Portal Order Fulfillment Ordering systems OE LMR etc. Order processing Rx Blood Lab Rad etc. Delivery & Documentation ... Patient Components Patient Status Admin Components Site Admitting Systems UCM KM ED Tracking BPM OR Scheduling Catalog Editor eMAR Labs etc. Admin Portal Registration Data Integration Terminology Services CDSS CDR Services EMPI Services Order Catalog Services Data Layer Terminology Repository Knowledge Repository CDRs (Labs, Vitals, Problems, Meds, Orders, Allergies, etc.) EMPI Order Catalog and Dictionaries Infrastructure Data Center Services, Devices, Networks, Security, Virus Protection, Middleware, Performance Monitoring Event Scheduler Notification Service Source: “Partners Strategic Plan for an Integrated Clinical Information System (ICIS),” Version 1, December 2005, Partners HealthCare, 2005. prepared by rmk 081310 11 PHS Approach to LMR/CPOE Deployment  embedded research: ◦ I2B2/National Center for Biomedical Computing ◦ Center for Connected Health ◦ Clinical Informatics Research and Development ◦ Center for Personalized Genetic Medicine ◦ etc…………………..  engage the field: ◦ scholarly and trade publications ◦ professional society meetings and publications ◦ government sponsored research ◦ participation in government sponsored panels, conferences and working committee prepared by rmk 081310 12 A Model for DSS/KMS Symbiosis as Applied in the Context of PHS 1 Data Warehouse Data from PHS Medical Delivery Systems 2 3 Analysis Leading to Decisions on Preferred Therapies Added to CPOE Knowledge Base 3 4 5 Applied to Actual Patient Care Outcomes Extracted to DSS Activities and Outcomes from Patient Care Captured as Transaction System Data 6 7 prepared by rmk 081310 13 Session 13: Partners Healthcare System (PHS) Case According to government sources, U.S. expenditures on health care in 2009 reached nearly $2.4 trillion dollars ($2.7 trillion by the end of 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 what is needed is an integrated electronic medical record (EMR) system and associated information technologyenabled processes.3 While the information systems currently available area may meet the needs of the industry, the question remains as to what is required within and by the health care services organization to achieve a satisfactory response to these dual challenges. At the present time, Partners Healthcare System (PHS) maintains a centralized digital records library on over 5 million patients, augmented in real-time by data, textual comments, and artifacts (i.e. x-rays, MRI’s, EKG’s, etc.) as these patients visit doctor offices, receive hospitalbased or home care services, and obtained prescription medications and other therapies. Procedures are in place to ensure the data quality and integrity of these patient files. Going forward, any health care professional across the network can access a patient’s complete record, ensuring accurate, timely, and comprehensive information sharing about that patient’s medical history, allergies, current treatments, and so forth. In and of itself, this investment in this electronic medical records system (EMR) - called the Longitudinal Medical Record or LMR within Partners - is expected to reduce delays in service delivery, mistakes in treating the patient, and overall health care costs. When coupled with a Computerized Physician Order Entry system (CPOE) to inform the selection of drugs and appropriate treatment, PHS health care professionals are 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. Partners HealthCare was founded in 1994 by the partnering of Brigham and Women's Hospital and Massachusetts General Hospital and became 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, eleven hospitals including its two founding academic medical centers, specialty facilities, community health centers and other health carerelated entities, and an ongoing affiliation with the Harvard Medical School. In 2008, Partners HealthCare serviced approximately 2.9 million outpatient visits, processed 20 million prescription drug orders, and admitted patients 149,000 to one of its hospitals. Its facilities at that time included 3,500 licensed hospital beds, serviced by 40,000 (FTE) employees across its network of affiliates, including 6,000 independent but affiliated physicians. For FY2008, 1 Plunkett Research, Ltd., (2008). “U.S. Healthcare Industry Overview,” www.plunkettresearch.com/Industries/HealthCare/HealthCareStatistics. 2 Leape, Lucian L. and Berwick, Donald M. (2005). “Five Years After To Err Is Human: What Have We Learned?” Journal of the American Medical Association 293(19):2384-2390. 3 Stead, Willam W. and Lin, Herbert S., editors (2009). Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions (Washington, D.C.: National Academy of Sciences, National Academies Press). prepared by rmk 050714 Page 1 Session 13: Partners Healthcare System (PHS) Case Partners generated over $7 billion dollars in revenue and conducted approximately $1 billion dollars worth of biomedical research. PHS maintains a substantial information management arm. The 2009 information Systems (IS) team comprised 1,500 employees operating out of nineteen locations in the greater Boston metropolitan area. With an operating budget of $196 million dollars in FY2009 and a capital FY2009 budget of $68 million dollars, IS supported 80,000 end users and 82,000 networked computer devices running in 140 Partners’ locations. In an average month in 2009 the IS organization answered 18,000 help desk calls, and over the course of that same year managed 250 major information technology (IT) projects for the enterprise. To realize its information management objectives, PHS has invested heavily in information technology over the years and hired some of the best information management professionals in the industry. PHS recognized early on that to be successful in the deployment of enterprise systems, such as LMR and CPOE, 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, vital signs, et al.; textual information, namely the transcribed comments of those health care professionals with whom the patient interacts; and objects, such as x-rays, MRI scans, and the like. 2. decision support processes that support the medical practitioner in making the best recommendations for drugs and other therapies based upon their likely benefits (i.e. positive outcomes) to the patient in question 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. Going forward the operational requirements faced by PHS member institutions in this regard are two-fold. One the one hand, each institution is obliged to establish processes to capture all on-going 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, it is also essential that patient information residing anywhere within the network 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 have proven flexible enough to deal with the differences posed by the various information systems and digital record formats extant within PHS. Key among these prepared by rmk 050714 Page 2 Session 13: Partners Healthcare System (PHS) Case innovations was the adoption and widespread use of a Computerized Physician Order Entry system (CPOE) that captures patient prescriptions and other doctor-assigned medical therapies. The successful implementation of these information systems depended largely on their adoption and use by health care practitioners across the PHS network. To that end, the rollout plan involved service delivery process reengineering as well as the extensive initial training and ongoing support of end users. In addition, the IS unit provided a robust, integrated platform for the collection, processing and dissemination of information across the PHS network, and they also worked to ensure the quality and integrity of the data going into these systems and processes. The new data management platform embraced a so-called “service oriented architecture.” The attributes of this platform included: • • • • • • • A single, enterprise repository and list for each of the key data types (allergies, medications, and problems ) All software capable of reading from and writing to these lists Standard data definitions applied to support the back-end aggregation of key clinical data for decision support, and quality reporting Standards for clinical knowledge across the enterprise Knowledge Management process and procedure for achieving clinical consensus on the rules governing system decision making processes Variation in the workflow of applications that are consistent with PHS medical and service delivery practices Workflow-based applications should demand some key work processes and data displays that lead to demonstrated superior results4 The implementation of the LMR within PHS also called for a high level of data quality. The mechanisms for data collection, validation, cleansing and warehousing, as part of enterprisewide process improvement, were all made more rigorous. In addition, the IS organization faced the need to review the rules engine that enabled its CPOE platform. Over the years, millions of rules, concerning such subjects as prescribed dosages, drug interactions, the recommended sequencing of therapies, and the like, had found their way into the CPOE knowledge base. The provenance for many of these rules remained obscure and the relevance/accuracy of others were in doubt. Given the vital importance of a current and accurate set of rules with CPOE decision-support system, IS took on the re-documentation and clean-up of the system’s knowledge base, as well as the establishment of a more rigorous process for the ongoing maintenance of rules engine. Like the rollout of LMR, the improvement of the PHS knowledge management process progressed in phases. The clean-up phase gave way to a more formal assignment of content stewardship by subject matter experts. This led ultimately to the regular authoring and updating of best practices that better informed health care delivery across the PHS network.5 4 Partners Healthcare System (2006). “Partners Advanced Clinical Informatics Infrastructure,” Partners HealthCare, p 6. 5 Hongsermeier, Tonya; Kashyap, Vipul; and Masson, Robert (2009). “Collaborative Authoring of Decision Support Knowledge: A Demonstration,” Partners HealthCare. prepared by rmk 050714 Page 3 Session 13: Partners Healthcare System (PHS) Case Postscript: On May 18, 2012, Partners announced that it plans to retire its patient electronic records system for patients resident in affiliated Partners hospitals. The original Partners system, which began operations in the 1980’s, was built in-house. The organization will license a single commercial system developed by Epic Systems Corporation, headquartered in Wisconsin. The project was expected to take 10 years to complete at a cost of around $600 million and will provide all hospital care givers with immediate access to vital patient information. In short, the investment should improve the integrated delivery of healthcare services within Partners. The LMR system discussed above will still be in use for the capture and tracking of outpatient information. Glossary: • Computerized Physician Order Entry (CPOE) System – an information system that is employed by physicians and other healthcare practitioners to directly enter orders for medications, diagnostic tests, and ancillary services. Current versions of these systems typically include decision support tools and an automated knowledge base to inform decision making where both the vendor of the system and the healthcare professionals who use the system may enter information and rules to influence the systems recommendations. • Database – A structure and efficient mechanism for the storage, description and management of discrete data elements and bodies of agency information. • Decision Support System (DSS) – An IT-enable system that facilitates the integration of critical agency information so that management may employ that information to inform planning and decision making. • Electronic Medical Record (EMR) system – an information system that facilitates the collection and consolidation into an integrated digital record all the information about a given patient over time, including: medical data, such as age, weight, height, vital signs, et al.; textual information, namely the transcribed comments of those health care professionals with whom the patient interacts; and objects, such as x-rays, MRI scans, and the like. • Infrastructure – The backbone of IT delivery, the networks, communication services, operating systems, servers, desktops, and related platforms, products and services that provide IT capabilities to the end user. • Knowledge Management (KM) – A range of practices used in an organization to identify, create, represent, distribute and enable the adoption of insights, best practices, and experiences. Such insights and experiences comprise knowledge, either embodied in individuals or embedded in organizational processes or practice. KM efforts typically focus on organizational objectives such as improved performance, competitive advantage, prepared by rmk 050714 Page 4 Session 13: Partners Healthcare System (PHS) Case innovation, and the sharing of lessons learned • LMR – the Longitudinal Medical Record; Partners HealthCare’s internally developed electronic medical records system. • Medical Informatics - The intersection of information science, computer science, and health care, medical informatics explores, designs and delivers the information management services required to optimize the acquisition, storage, retrieval, and use of information in health care and bio/medical organizations. • Service Oriented Architecture (SOA) – An approach to systems design and deployment that aims to loosely couple applications so as to facilitate access to particular bodies of data or system capabilities without recourse to more formal systems integration. In the context of the PHS information management platform, a service oriented architecture more readily accommodate information sharing among organizational and business entities operating different information systems but needing to share a common body of content (e.g. data, text documents, and digital objects, such as photographs and x-rays. prepared by rmk 050714 Page 5
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