Case Study

When IT Matters: Improving Care Delivery and Patient Outcomes through

About CHIME The College of Healthcare Information Management Executives (CHIME) is the professional association for chief information officers and other senior healthcare IT leaders. CHIME enables its members to collaborate; exchange ideas; and advocate the effective use of information management to improve health and healthcare in the communities they serve.

Technology

September 2013

Making Information Flow: Even with EHRs, Theres More Than Meets The Eye
William A. Spooner Senior Vice President and CIO Bill Spooner has been chief information officer (CIO) for more than 15 of his 30 years at Sharp HealthCare. He has led an aggressive IT effort that placed Sharp on the Hospitals and Health Networks 100 Most Wired list for 12 of the lists 14 years. IT was cited for its contributions to Sharps 2007 Malcolm Baldrige National Quality Award. Sharp was an early leader in electronic health records and has received several awards for its consumer website.

Key Terms
Data mapping: The process of developing linkages between records and information systems with two distinct data models for the purpose of achieving data integration. In healthcare, data mapping between systems helps bring patient records from different systems together in a coordinated fashion. Standardized terminologies: The use of one set of language for specific areas of healthcare, such as using one set of clinical terms to describe patients conditions. Structured terminologies have been standardized for laboratory procedures and values, clinical conditions, and more. Patient matching: Efforts to connect unique patients to their personal data, eliminating any possibility that health information is mismatched and linked to the wrong person. Patient matching is currently difficult because there is no agreed upon way to identify patients. It is not always certain that patients information is uniformly identified even within healthcare organizations. Patient matching is even more challenging when attempts are made to share healthcare information with different provider organizations. Health information exchange (HIE): The process of making patients healthcare information available for sharing among healthcare organizations. HIE is believed to be critical to better coordinate care and reduce healthcare expenditures. However, HIE is challenging for a variety of reasons, including being able to quickly and accurately match patients in a region with their medical information.

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Sharp HealthCare has worked for more than a decade to get patient information into electronic medical records. The San Diego-based not-for-profit organization, through its facilities and associated health plan, is responsible for the healthcare of an estimated 4.5 million healthcare records, representing more than 2.3 million patient visits per year. Despite all the advances over the years, digital health records are a complex undertaking that, at times, can require a lot of hands-on, manual effort. Change is a constant at Sharp, as it is at healthcare organizations across the country. The implementation of new clinical information systems brings challenges in linking them to each other. Organizations are forming relationships with other providers in ambulatory or postacute care settings running different information systems and typically having less IT prowess. And area provider organizations that have competed for years are trying to put aside differences to work on large-scale healthcare information exchange projects. Sharps situation is one that is typical, faced by providers nationwide. The pressure is growing for providers to move to electronic health records and increasingly be able to share data with other organizations, said Bill Spooner, senior vice president and CIO at Sharp. In an era of frequent mergers, innovative provider affiliations, collaborative care arrangements and declining revenues, it is essential to view our patients across that entire care continuum. Robust interoperability is a competitive advantage deserving greater appreciation. In San Diego, each organizations IT challenges are often made harder by financial pressures and regulatory requirements; frequent new versions of existing products; rapid evolution in IT product offerings; and the demands of the change and training process for a clinical staff already conflicted by anything that take time away from caring for patients.

Change is a constant at Sharp, as it is at healthcare organizations across the country. Implementing new clinical information systems brings challenges in linking them to each other.

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Despite the constantly shifting sand, the organizations IT department deals with a very specific mission. It goes back to having the right information with the right patient, and having the information complete and accurate, said Sarah Harrington, who works as manager of the master patient index department at Sharp. Missing even one medication in the record can make a big difference to the decision that is made by a clinician.

Data Mapping Issues with Electronic Health Records

Sharp is an integrated regional health care delivery system located in San Diego, operating four acute-care hospitals, three specialty hospitals, two affiliated medical groups, rehabilitation services, home care, hospice, long term care and a health plan. Its hospitals are using one medical records system, from North Kansas City, Mo.-based Cerner Corp., while the physician offices in its affiliated medical groups are using a medical records system from Chicago-based Allscripts Inc. Even though the different information systems are operated by Sharp and may contain information on the same patients, information doesnt flow freely between them. Thats where the work begins, says Elizabeth Renfree, director of interoperability for Sharp. Were not exchanging data between the two systemswere mapping the data into our HIE for a common view, Renfree says. The distinction is important; Cerner and Allscripts systems use different code sets and different standards as the basis of their systems, even though they both contain patient medical information.

Sharp operates four acute-care hospitals, three specialty hospitals and other sites offering ancillary services.

Were not exchanging data between the two systems were mapping the data into our HIE for a common view Elizabeth Renfree, Director of Interoperability

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Why arent they the same? Its like comparing Macs to Windows-based computers, says Betsy Ellis, principle application analyst in Sharps interoperability department. They use different code sets and different dictionaries. Cerner may code an allergy to peanuts one way, and Allscripts may code it an entirely different way. As each application evolved, they used these different codes and standards. For clinicians to get the full picture of a patients health story, Sharp uses another application, from dbMotion, to bring information together from its inpatient and outpatient system, creating a virtual single patient record in which data is brought together and aggregated from a variety of sources. Data is mapped into the dbMotion system from the Cerner and Allscripts applications. To have a medication appear as like for like, you have to do a fair amount of translation between the two systems, Renfree said. The mapping enables grouping and harmonizing of patients medical records, so that clinicians have an easier time looking at trends and dont have to piece together record components. All kinds of components from the two systems need to be mapped the list includes allergies, medications, diagnoses, procedures. There are thousands of pieces to be mapped, and the job never ends. Its a forever process, Renfree says. Theres always new medications, new processes. Mapping is an IT staff function; at Sharp, its done by three registered nurses who have a clinical background, Ellis said. The majority of these components need some sort of clinical review to make sure theyre mapped (into the virtual record) correctly, she says. Its critical that you have people that really understand the data and understand the application. Sharp uses a large database, called a data warehouse, as a central repository to contain data it needs for reporting and analysis, and that enables it to do very sophisticated analysis. However, healthcare organizations are becoming larger as they form accountable care organizations (ACOs). As ACOs attempt to manage the health of larger populations, theyll likely face mapping challenges in trying to get a unified version of patients health records, Renfree says. That also will happen at Sharp, as it aims to share information with other community physician groups with which it works. If these groups have a records system from another vendor not Allscripts, but eClinical Works or NextGen, for example the mapping process will have to be repeated. Nationwide, more than 400 vendors provide EHR systems to physician practices, and none of those vendors have more than 11 percent of the market share, according to SK & A, an Irvine, Calif.-based research firm.

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The Challenge of Standardized Language in EHRs

While Sharp uses Cerners product as its main hospital information system, there are other specialized information systems that meet very specific clinical needs within the hospital, such as gathering and monitoring pulmonary results in a specific department. To get data from niche systems into the main record, Sharp relies on one of two approaches. In one, vendors may have already written interfaces pre-developed computer code that enables information to go from one system into another. If two systems havent been linked in the past, vendors may charge to write an interface for the provider. In the other approach, an organization may use an interface engine, which is a software application that enables different computer systems to access and exchange information. Increasingly, information systems in healthcare use HL7 as a standard messaging protocol, which helps different systems exchange and integrate information. While interface engine technology helps, Sharp needs technology savvy staff to use it, Renfree says. They are able to write the code within the interface engine application so that information flows appropriately, she adds. To get information systems from various vendors to share data, you need people that really understand how interface engine technology and HL7 messaging work. Another hurdle is getting everything into the same language. While there are ways to move it back and forth between systems, computer-based records rely on having similar terms so that data are properly sorted, tracked and reported. However, healthcare has a rich history of using multiple descriptions is it heart attack, acute myocardial infarction or cardiac arrest? Hypertension, arterial hypertension or high blood pressure? Ibuprofen or Advil? Vendor applications are starting to use standardized languages to get everyone on the same page. For example, medical terminology is moving toward the use of SNOMED Clinical Terms; differences in drug descriptions can be resolved through the use of RxNorm, which provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management. Still, differences in terminology usage exist between vendors systems, and Sharp gets around these by mapping to standard medical terminologies into its own corporate health information exchange. Challenges of Standardized Language in EHRs While Sharp uses Cerners product as its main hospital information system, there are other specialized information systems that meet very specific clinical needs within the hospital, such as gathering and monitoring pulmonary results in a specific department. To get data from niche systems into the main record, Sharp relies on one of two approaches: Vendor written interfaces Interface engine technology

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The Complexities of Resolving Patient Identities

The use of electronic health records ups the ante for making sure that there are no mistakes in matching patients with records. While this sounds simple, the matching process becomes complicated for a variety of reasons. For example, patients may come for treatment at a variety of settings they may see their own primary care physician for treatment, a specialist for a consultation, a lab for testing and an inpatient hospital for treatment and recovery. When paper records were the norm, each provider kept their own set of records, and records were sent by courier or fax when they were needed. Now, in an electronic record world, records are more easily accessible, and different providers using different systems may have different approaches or protocols for identifying patients. On the patient side, its not always easy to tell patients apart. They may have the same names, insurance numbers or addresses. Because of the ease of access to electronic records, its critical to match the right patients to the right records. Record duplication gets a lot of attention at Sharp, which operates a master patient index department to sort through identity issues. Supervised by Tommie Egbert, the staff of 10 regularly looks into questions about patient identities to ensure theres only one set of medical records per patient. Its gotten easier. When Sharp implemented electronic medical records in 2001, the department was created to deal with identity duplications. When we first started the department, we were creating 18 duplicates a day across the whole system, Egbert says. Now, were doing about four duplications a month, so its had a huge impact.

When paper records were the norm, each provider kept their own set of records, and records were sent by courier or fax when they were needed. Now, in an electronic record world, records are more easily accessible, and different providers using different systems may have different approaches or protocols for identifying patients.

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New duplications arise when patients come to Sharp for treatment, and information systems or Sharp staff, identify potential records duplications. In addition, the staff works on existing duplicates in the records system, which have not been prompted by a current patient encounter, says Sarah Harrington, manager of the master patient index department. Making a determination of a patient-record match often takes only a few minutes and can be done at a computer screen, but its a very manual process that requires a bit of sleuthing. We take clues from a lot of different sources, like looking at drivers licenses, signatures, consents for treatments or other things, Egbert says. Before we do a record merge, we want to make sure it is the same patient. Sharp also is using advanced identification technologies to ensure patient identities. Its using palm vein identification technology to biometrically identify patients matching each persons unique vein structure in their palms to their records takes the guesswork out of matching patients to records at Sharp. Internally for Sharp, it has benefitted us both in the quality of care and for cost, Harrington says. It helps eliminate misidentification, and that helps quality; for reducing cost, if someone has had an MRI in one Sharp facility, a physician may not have to order another one if we can link the records. It saves cost for the patient, and cost for the system overall.

Wider Sharing of Patient Information Will Require Extra Work

But that complexity will rise again when Sharp hopes to exchange patient information through a health information exchange (HIE) thats developing in the metropolitan area. Because people may go to any provider for treatment in the San Diego area, patient matching will be a challenge in exchanging data with other health organizations, Harrington says. Weve been working with various community partners in San Diego on the San Diego Regional HIE, she says. Each healthcare system has its own process for correcting record duplicates and identifying patients. They use different terminology. They have different levels of confidence as to whether something is an error. Weve done a couple of test merges between organizations, and they have gone well. In developing an HIE, this is one of the big challenges. This will create more work for us, and we all have limited resources, so each one of us will have to add this to our workflows. A universal way to identify patients, through the use of a standardized patient identifier, would increase patient safety and spare spending now necessary to ensure patient identities match records across a region, Harrington says. I understand why theres resistance to the idea, but anyone whos witnessed or been involved in an error related to a patient-record mismatch understands the importance of this, she adds.

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A universal way to identify patients, through the use of a standardized patient identifier, would increase patient safety and spare spending now necessary to ensure patient identities match records across a region.

Patient matching also becomes critical because of the sensitive nature of individuals medical records. HIPAA regulations govern the release of personal health information (PHI), giving patients the final say in who can see what portions of their records. Sharps electronic health records system enables it to associate these permissions with the data in a patients records, but the process becomes exponentially more difficult when patient data begins to be shared in a regional health information exchange, such as the one being developed in San Diego. We (explain permissions) verbally now with other providers, Harrington says. Weve all felt a little uncomfortable with this process; you have to trust that others are going to guard that PHI, and they have to trust us. It will get complicated, because well have to explain to the patient what [the HIE] will mean about their record, Renfree says. Patients understand that if they come to a Sharp hospital, their records will be shared within Sharp. Now, theyll need to give consent before their records can be shared in the San Diego Regional HIE. Standardized patient identifiers also would provide critical assistance to providers who will increasingly be required to be able to share patient data in HIEs. Patient matching across the community segment will be really difficult for just about everybody, Renfree says. Protecting privacy and security is important; doing it is technically difficult and organizationally difficult, but its all to the benefit of the patients.

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About Sharp Sharp HealthCare is a not-for-profit integrated regional health care delivery system based in San Diego, Calif. Sharp includes four acute-care hospitals, three specialty hospitals, two affiliated medical groups and a health plan, plus a full spectrum of other facilities and services. As San Diegos health care leader, Sharp has an unwavering commitment to excellence and passion for caring. At the forefront of Sharps commitment to excellence is The Sharp Experience, a sweeping performance improvement initiative launched in 2001. This initiative has resulted in numerous advances in clinical outcomes, patient safety enhancements and organizational and service improvements. Sharp was named a recipient of the 2007 Malcolm Baldrige National Quality Award and was the first health care system to be named a gold-level award recipient by the California Council for Excellence (CCE) for the California Awards for Performance Excellence (CAPE) program, the state-level affiliate of the Baldrige Award, in 2006. Sharps passion for caring is shared by our 2,600 physicians, including more than 1,100 physicians in our two affiliated medical groups Sharp Rees-Stealy and Sharp Community Medical Group and more than 15,000 employees. Together this team is working to make Sharp San Diegos best place to work, the best place to practice medicine and the best place to receive care.

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