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Are the Technical Aspects of EHR Integration Overstated?

"If an Epic hospital is looking to gain market share,they are going to start with other Epic hospitals because it's an easier step than a MEDITECH or Cerner hospital."

By Kyle Murphy, PhD

- The triple aim of healthcare reform relies on improvements to care coordination that are in turn dependent on the ability of various healthcare organizations to integrate effectively. The task of EHR integration is a challenging one, bringing two cultures of care delivery under one roof and looking to implement a singular way of doing things.

EHR integration is oftentimes not technical but culture

Mergers, acquisitions, and affiliations are common features of the current healthcare landscape, but the challenges they raise are by no means simple. Complexity is the order of the day and many healthcare organizations have yet to realize that.

That was the opinion of executives at health IT consultancy Impact Advisors — President and Co-Founder Andrew Smith, Vice President Lydon Neumann, and Vice President John Stanley — who sat down with EHRIntelligence.com at the College for Healthcare Information Management Executives (CHIME) Fall Forum earlier this month to discuss healthcare integration.

"It starts with the premise that they have underestimated the complexity," Neumann said. "If you start with that premise, then it usually takes longer than they expected because the executives think this is pretty straightforward. The reality is much different. If they planned well and budgeted well, it can go faster, but it requires some sophistication."

While the group specializes in health IT-related projects with integrated delivery networks, academic health centers, children's hospitals, and large physician groups, its work has focused on several non-technical areas that are equally important to healthcare integration.

READ MORE: Success of a Step-By-Step EHR Adoption Approach at HealthNet

"The notion of culture is key. What we find ourselves doing more and more is operations integration and change management. IT just happens to be the vehicle by which those things have to happen," added Stanley.

That is not to say that health IT plays a lesser role in these multi-layered integrations. They may actually be the reason certain agreements are struck and others are not.

"If an Epic hospital is looking to gain market share," Stanley continued, "they are going to start with other Epic hospitals because it's an easier step than a MEDITECH or Cerner hospital."

The technology, however, tends to give way to more pressing issues as two ways of doing things come head to head.

"A lot of times it just gets down to winners and losers," Smith observed. "There isn't one way that's better than the other — it's just different. I had an implementation years ago that ground to a halt because the two flagship hospitals couldn't agree on whether they were going to use Celsius or Fahrenheit, and that had nothing to do with Celsius or Fahrenheit but everything to do with which culture was going to be predominant."

READ MORE: Epic, Cerner Beat Out MEDITECH in Small Hospital EHR Adoption

Technology just so happens to be the means that brings these two forces together and that's when it can end up giving way.

"All of this change in the standardization could and should happen outside of any technology implementation but it typically doesn't," Smith maintained. "Technology is often the tip of the spear. They are using this as a catalyst to drive normalization. Is that the right way to do it? Probably not. But that's how most places do it."

While these cultural differences are surmountable, their resolution is first necessary to ensure that the technology goals of the healthcare integration can be set and ultimately met.

The technology side of integration

The typical goal of a healthcare integration is a set of standard workflows and practices across all parties. Getting to that point is easier said than done.

READ MORE: EHR Use Nearly Universal in Hospital Outpatient Practices

"Even in the most homogenous of MEDITECH, Cerner, or Epic clients, they have hundreds of other systems involved," Smith revealed. "If you were to look at things that slow down implementations at the end of the day, it's very predictable — you can count on third-party interfaces, training and security, printing, and data conversion."

And even if one health IT system wins out, it does not necessarily follow that only one system is set to be implemented. Standardization comes at a cost to all facilities involved in the integration.

"It can be way more expensive than they think. 'We'll just put the EHRs together.' That means re-implementing one of them and all the change management, all the adoption, and all of those sort of things that would be seemingly simple because they are already on an EHR," Stanley noted.

There are many examples of health IT-related setbacks that befall many a healthcare integration. But one that is common to large-scale integrations is what becomes of mechanism for identifying the right patient — that is, the master patient index (MPI).

The joining institution tends to be on the losing end for the MPI in having to adopt to the practices employed by the enterprise version. However, some burdens are most certainly shouldered by both parties, Smith demonstrated:

If you're going to merge MPIs across two organizations, chances are pretty good that the MPI Organization 1 has probably isn't that clean — a 10- to 15-percent dupe rate is not out of bounds. Organization 2 is going to have the same issue. So right off the bat, you have 15 percent for both organizations that isn't going to match. What you should do is drive those down to low single digits like 2- to 3-percent dupe rates, and then you still need to bring those together.

The end-goal may be automation, but data cleanup requires old-fashioned elbow grease. "You can automate the process; you can't automate the steps you go through in cleaning it up," Neumann declared.

The role of health IT consultancies in bridging these gaps between healthcare organizations and within them as well highlights how non-technical factors become features of technical components. Furthermore, it gives more credence to claims that the work of professionals such as these focuses on much than technology.

"The catalyst might be technology, but very little of the kind of work we do is technology related. It's more around workflow, process, people. The technology is 20 percent; people are 80 percent," Smith concluded.

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