Lehigh Valley CMIO: ‘Good, Bad and Ugly of Best-of-Breed’

The Lehigh Valley Health Network in Allentown, Pa., has been a pioneer in many areas of health IT. For instance, it finished computerized physician order entry (CPOE) deployment with closed-loop medication administration back in 2005. But the leading edge can also be the bleeding edge, and because Lehigh Valley started early, it often had to build solutions from the ground up.

Speaking at the Children’s Hospital of Philadelphia’s Healthcare Informatics Colloquium on May 30, Donald Levick, M.D., M.B.A., Lehigh Valley’s chief medical information officer, said that by not limiting itself to working with a single main vendor such as Epic, his three-hospital organization has been able to do many innovative things, such as create a remote intensive care unit workstation, by cobbling together solutions from multiple vendors and adding web-based applications. (Its remote ICU automates the flow of information from ICU monitoring equipment, which allows intensivists to better monitor patient progress.)

“With a single-source system, you get what you get, and some of the functions are not as advanced,” Levick said. “With a best-of-breed system, we have the freedom to build what we want.” Lehigh Valley has created its own web-based applications around functions such as oncology ordering and turned to third-party applications for others such as medication reconciliation and generating discharge instructions.

But the downside involves writing point-to-point interfaces between all the systems in place. The need to build interfaces has been longstanding, because even though the main ambulatory EHR is GE Centricity and the inpatient system is also called GE Centricity, those products have different origins and don’t talk to each other very well, he added. The emergency department uses software from T-System, and there are other tools for PACS and cardiology systems. Lehigh Valley uses Hyland OnBase for document imaging.

Levick’s PowerPoint demonstration included an interface map that was more crowded than the New York City subway system map. “This map speaks for itself,” he said. “We have several full-time staffers just building and maintaining these interfaces. It is our biggest problem,” he said, adding that prioritizing which interfaces to work on next is also a challenge.

One thing that may help is a clinician portal that is being built to pull data from all the outpatient and inpatient systems into a single view (although it will be read-only at first).

In addition to creating a new data warehouse and mapping the data elements, Lehigh Valley is using data normalization tools to ensure that the data regarding a patient in one system are matched up with the data on that same patient from another system. (That also requires a data governance effort to determine which internal teams will be stewards responsible for specific data sets.)

Because physicians don’t want to log in and out of the dozen or more systems they might need to touch every day, Lehigh Valley has a single-sign-on application. But Levick says that is just one more application to maintain, and if something changes about a piece of software, it can break the single-sign-on link for users. Another downside is that the best-of-breed system is more difficult to provide support and training for. “Users call the help desk and they’re not even sure which system they are in,” he said.

So the benefit of the best-of-breed approach is that it allows Lehigh Valley to be innovative and bring in or create cutting-edge tools such as its remote ICU; the problem is that the interfaces require intensive maintenance. Organizations like Levick’s have to wrestle with the decision of whether it would be worth it to take a step back in functionality in some areas to gain the integration benefits of a single vendor. “It is a gigantic decision,” he said.