Emergency department Information Systems Best of Breed VS. Enterprise module

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Emergency Department Information Systems (EDIS), Best of Breed VS. Enterprise module.

Selecting and implementing an Emergency Department Information System can be a challenging experience. The majority of patients coming through the department will be discharged to home, requiring an ambulatory electronic health record that needs to be functional, simple and speedy to use. A smaller (but sicker) group of patients will require extensive evaluation and care with multiple caregivers, then require admission to an inpatient unit or critical care area. Integration with the enterprise health record for access to previous encounters, medications, previous problems, and the ability for Emergency Department (ED) developed data to flow into the inpatient record can improve the delivery of safer care. Clinicians and administrators who have the task of selection of EDIS struggle with finding the right mix of functionality vs. integration. Best of breed applications generally have the functions that clinicians are seeking to care for their patients. The vendors have been able to develop products that have good user interfaces, relatively easy documentation tools, and are marketed to ED physicians at national meetings. Enterprise ED module solutions have been slower to offer the same functionality but may have the advantage of integration with the other applications in the system. The incorporation of emergency department data as part of qualification requirements for meaningful use in the ARRA legislation has added another layer of complexity to the decisions regarding implementation and optimization of EDIS. Finding the right balance of functionality and integration will be necessary and crucial to success.

Historically most hospitals began with departmental information systems for billing, laboratory, pharmacy and radiology. Interfaces with a clinical data repository integrated the data and allowed users access from single workstations (rather than going to workstation in each system). This approach allows selection of the best product available for each application (best of breed) and stepwise build of the system. The difficulties with this approach are the many interfaces between systems which must be built and maintained, managing multiple vendors, data back-up reliability and maintaining availability of the system. Another approach to the electronic health record is to use a unified data base fully integrated with each application. This minimizes or eliminates the need for interfaces and provides integration at the data level. A simpler configuration is possible with fewer hardwired requirements and it is easier to back up data and maintain availability. Disadvantages to this approach include the loss of any existing legacy systems, dealing with a single vendor which may have less desirable (or nonexistent) applications in some areas. A third approach is to develop a hybrid with use of existing systems but selecting a preferred vendor to move toward a unified data base. This allows stepwise build, fewer vendors and less costly data integration than best of breed approach. Multiple interfaces dealing with multiple vendors are still required. Carter J, Electronic Health Records, A Guide for Clinicians and Administrators, 2nd ed, ACP Press, 2008

Health care systems should have a vision for their future state with a road map to get there. Many hospitals and emergency departments are moving toward an electronic health record. ARRA financial incentives have sped up plans for implementation. Decisions regarding best of breed, hybrid, or single database enterprise systems will have significant financial impacts. The clinicians, informaticians, information technologists, financial officers, administrators and board members need to reach consensus on the best course to follow for each institution.

“The lack of an integrated system results in diagnostic errors, failures to identify deteriorating patients, communication errors, and inefficient work, all of which contribute to worker stress and burnout. … Clinicians are presented with ever-increasing amounts of raw data, often in chaotic environments with the expectation of filtering data, prioritizing risks, and making informed treatment decisions...Consequently safety has not improved. Ironically the signal – to – noise ratio in complex health care settings may be worsening despite advances in technology and computing power...Clinicians and administrators are trying to build hospitals piecemeal, buying technologies one by one, hoping to make equipment and technology talk to each other. Yet in doing so they are increasing health care costs and reducing health care quality. Health care needs a systems approach to integrate the insight and work flow of clinicians with the increasing amount of health care technology and equipment.” Mathew S, Provonost P, The Need for Systems Integration in Health Care. JAMA, March 2, 2011; 305(9):934-935.

Best of breed, hybrid and enterprise approaches to emergency department information systems vary but some in each category have been successful. Application integration and functionality differs between vendors. Overall the market appears to be shifting toward enterprise EDIS. 93% of institutions using enterprise EDIS module state it is part of their long term plan. 69% of best of breed institutions plan to stay with the solution long term. Some are using best of breed as a placeholder while waiting for the enterprise EDIS to improve functionality then switch. The future of independent best of breed is unclear, will probably decrease in numbers, possibly partnering with enterprise systems. KLAS, EDIS 2010, Functionality vs. integration, finding the right mix. Performance report, November2010; WWW.KLASresearch.com

Submitted by Jim Wiedower