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About the series

As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.

H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.

Much of the movement along the care continuum is directed by physicians, who are centrally responsible for a patient's health status as well as recovery from events requiring hospitalization.

Physicians and hospitals aspire to establish coordination through information technology, but financial and technical barriers continue to complicate that crucial exchange of patient details and population data.

The federal government's incentive program for meaningful use of electronic health records has led many a medical group to consider working with a hospital on EHR implementation. But the financial hit from both initial deployment and future operational costs, not to mention being able to share information back and forth, constitutes a business challenge that can't be underestimated, says Russell Branzell, president and CEO of the College of Healthcare Information Management Executives.

Long-term operational expense "is often two, three, four times the capital investment that you need" in bringing a hospital system's IT platform to physician offices, says Branzell. The time and money for that is compounded by an already-full plate of IT-related projects. "From ICD-10 to meaningful use to all the other initiatives under the umbrella of CMS, all of these have validity and purpose — they're just all happening at the same time," he says. "Now, where do you find the resources to extend [health IT] solutions into the community?"

Providers clearing the financial barrier find themselves up against the next obstacle: the technical difficulty of tying hospitals and physicians together in an interoperable information interchange that is reliable, affordable and yields a sufficient amount of information valuable to all. Even with recent industry movement to a common messaging standard, as well as requiring all EHRs to exchange a common type of patient summary document, information-sharing processes are far from uniform, says Charles Christian, vice president and chief information officer of St. Francis Hospital, Columbus, Ga.

"The first thing that everybody needs to understand, and I'm going to use good Southern English, is: 'This stuff ain't easy,'" he says.

For one thing, the messaging "standard" is more a framework, "a point of conceptual conversation," says Christian. IT vendors still can apply the same version of the so-named Health Level Seven International standard differently, and both sides of a transaction have to pound out differences in the semantics of medical terms and how they will be received and sent through software interfaces, he says [see case study].

The work to interface physician EHRs with those of hospitals and other practices, Branzell says, carries a high up-front cost — a single office of one to four practitioners "can use just as many resources as a hospital, as they're getting ready to deploy." Many hospital executives "go into this thinking, 'Well, I'll just throw my EHR out there and everything will be fine,' when it's actually more of a long-term and very significant investment of resources," adds Branzell, a former health system CIO.

The escalating trend toward employment of physicians by health care systems "gives a jump-start" to the hospital-physician connectivity challenge, Branzell says. "That's integration in its extreme — not just computer-system integration, but overall complete integration of the physicians into the care continuum." Academic medical centers have long had employed-physician models and a single platform for IT, and now a wave of medium-sized and even small community hospitals are joining that trend, he says.

That's been the approach of Vanderbilt University Medical Center, Nashville, Tenn., for more than a dozen years, during which it self-developed a hospital-based and ambulatory EHR used by all its doctors. But the advent of accountable care organizations, which necessarily take in a wider circle of health care partners than just owned facilities and practices, prompted Vanderbilt to adapt its EHR platform to a rapidly expanding network of affiliate organizations with varying IT infrastructure, says Deputy CIO George McCulloch.

Its mechanism for that broader continuum of care is more along the lines of a private health information exchange model rather than the outward extension of a proprietary EHR network, says McCulloch, adding that Vanderbilt cut its teeth on that approach when it applied its self-built EHR to a regional health information organization for the Memphis area. The Vanderbilt Health System IT network, he says, aims to get beyond basic data interchange and into figuring how to collect certain information from all participants to aggregate for analysis of care delivery patterns. That will help physicians of all ACO partners deliver care together, at the most appropriate location [see case study].

Case Study

The extent of information-sharing necessary to bind providers together can't be achieved by the current state of interoperability, which consists of sending and receiving snapshots of information in what's called a continuum of care document, says Vanderbilt's McCulloch. Care coordination requires a lot more lab, diagnostic and treatment data freely moving around than a high-level CCD summary can provide, he explains.

"We want discrete data that we can act on, that we can analyze, so that we can take a look at practice patterns and other kinds of things." A CCD, which he calls "a lump of data," isn't discrete enough and "isn't terribly helpful" in understanding what makes other providers tick. The challenge is to develop the basis for extracting certain types of information from the technology foundations of clinical affiliates by whatever standard means are available, either through vendors or building it in-house.

Achieving that will, for example, enable Vanderbilt to include patient detail from affiliates in a sophisticated system the medical center has been using for more than a decade to size up what a clinician is aiming to do and suggest one course of action over another based on available test results, patient condition and research findings. McCulloch says a key aim is to spread that decision support across the Vanderbilt continuum.

Case Study

Health care CEOs don't have to know all the nuts and bolts of making information flow from medical groups to inpatient facilities and back, but they have to know there are a lot of them to twist and assemble, says Christian of St. Francis. "There is a deep technical component, a lot of conversations" that can turn on what seems like very basic elements of clinical data handling.

"The great majority of it is going to be standard, but what I call an 'encounter number' somebody else may call a 'patient account number,' or someone may call it a 'record number.' " That's just a taste of what all sides of a system integration process have to agree on, which makes for a lot of manual work to get interfaces set up, he says.

The question is, how does that work get done? Even a 50- to 100-physician practice likely does not have the financial wherewithal for its own IT department; and no matter the size of a group, "they're all leaning upon their vendors for a lot of that heavy lifting related to a standard interface plugging into a variety of things." EHR vendors, though, have only so many quality pros spread across a big customer base to do such integration, Christian cautions.