UMass Memorial Health Care (UMMHC) has earned recognition as the top hospital in Massachusetts, second in the nation for cardiac care, and as a top-10 hospital for quality and safety by the University Health System Consortium, among other honors. Behind the scenes, however, the health system was becoming increasingly constrained by an aging information technology (IT) infrastructure, as well as internal processes and a medical record system that are primarily paper-based.

The hospital’s combination of manual processes and semi-automated clinical and business systems could not support anticipated increases for documentation and reporting, large numbers of new quality measures, and a strategic initiative to strengthen relationships with community physician practices.

UMass serves central Massachusetts and consists of a medical center with three campuses in Worcester, a large primary care and specialty medical group, and four community hospitals. Leaders at all levels of the organization recognized the implications of the aging IT infrastructure several years ago, and launched a strategic initiative to advance the health system’s IT architecture quickly and cost effectively.

The initiative encompassed the needs of both the ambulatory and acute care settings, leveraging existing “bright spots” in the current architecture such as a fully automated e-ICU and broadly deployed ambulatory electronic medical records (EMR). Interoperability was the centerpiece of the new architecture, ensuring the ability to link and share information within UMass facilities, as well as with outside organizations throughout central Massachusetts and New England.

Implementation will not be managed as a series of individual IT application projects, but as a single strategic initiative that is operations and process driven.

The challenge faced by the staff was how to ensure that investments in infrastructure and interoperability had equal visibility and, therefore, perceived importance with the more easily understood replacement of end-user clinical and financial applications. This visibility was important, since the infrastructure components for interoperability are an essential underpinning of the new information system strategy. Being able to offer referring physicians convenient, secure access to patient information, for example, is critical to improving both quality of care and patient satisfaction.

This same capability benefits the referring physician by reducing costs, while the hospital enhances its position of delivering high-value service to referring providers, while simultaneously being an organization with which it is easy to do business.

For UMMHC, an enterprise master patient index (EMPI) capability would be required to facilitate sharing information outside its facilities and practice locations, even after it had standardized a common clinical and financial system at member hospitals. Similarly, being able to synthesize healthcare data from multiple systems into a single, consolidated clinical view for each patient was essential in order to derive the full benefit from going paperless for all medical documentation.

From the outset, UMMHC recognized that the new IT architecture would consist of interdependent systems in which no single application could accomplish the strategic goals that were identified. Simply updating an out-of-date application, for example, without achieving interoperability objectives was a non-starter.

To reinforce this thinking, UMMHC established a single evaluation group responsible for identifying and selecting all key applications. This created a senior cadre of leaders throughout the health system who shared a common understanding of the diverse business needs, as well as the essential linkages and dependencies between the selected systems.

Interoperability was one of these key dependencies between applications, and the need for a clinical data repository (CDR) as an essential interoperability platform was acknowledged. UMMHC, however, wanted more than a traditional CDR focused only on the centralized storage and access of clinical information. Finding a solution with the sophistication to synthesize data from multiple, independent sources, both internal and from partners, was paramount in the search.

Three Choices to Consider

Semantic interoperability is an innovative capability different than the market has traditionally provided in a CDR. The evaluation process, however, also reviewed three alternatives: license a shrink-wrapped add-on to a particular EMR vendor or product; select a set of technology tools and pursue a largely custom solution; or license a product that could serve as a configurable platform solution.

Ultimately, staff decided a platform approach like that offered by dbMotion was the most appropriate. The academic nature of the organization, as well as the need to integrate with multiple application platforms both inside the health system and in the community, required the flexibility of a solution that could be customized.

This important consideration ruled out options tied to a single vendor’s EMR. The focus on cost-effectiveness and rapid deployment also excluded toolkit solutions requiring extensive customization. Staff discovered that with a platform approach, many of the cost and support advantages of a shrink-wrapped solution would be possible, along with a degree of the flexibility a custom solution would provide.

In addition to selecting responsive and functional technology, the approach was successful in its efforts to underscore the importance of interoperability to all stakeholders. The strategy for keeping interoperability front-and-center among the priorities of the new system was three-fold.

First, the replacement of core information systems and investments in new interoperability components, as interdependent and inseparable were clearly and consistently presented. Second, a single executive team responsible for making all solution and vendor decisions was created. This team would evaluate each component of the system in the appropriate context. Third, the interoperability components could not become buried within the data center, but instead needed to provide high-value services to clinical and business users early on.

Key Objectives

The EMPI, for example, is essential to sharing information at a transaction level between systems, but the key objectives for the first phase of the rollout are focused on using the EMPI as a shared source of registration information so that both registration and patient billing areas see immediate value. In the area of semantic interoperability, staff focused on a clinical repository solution that was paired with a clinical portal. In this way, the power and sophistication of the CDR platform could deliver immediate clinical benefits to the organization that were easy to articulate and demonstrate.

UMMHC already is seeing the benefits of the platform approach in that all of the architecture design that should precede developing a custom solution is already done. This time saver allows staff to get into the value-added details of implementation. The chosen solution, for example, effectively isolates the data architecture from the end user presentation layer, enabling staff to proceed with identifying and mapping data sources into the repository, while working with the clinical team in parallel on how the data is presented.

This implementation, including vendor selection and contract signing, was completed toward the end of 2008 just as the U.S. and world economy sank into recession. While this economic crisis has tested earlier decisions related to the new IT architecture, current plans are to stay the course and implement the new systems as anticipated. Implementation will not be managed as a series of individual IT application projects, but as a single strategic initiative that is both operations and process driven.

Interoperability was one of these key dependencies between applications, and the need for a clinical data repository (CDR) as an essential interoperability platform was acknowledged.

Interoperability will remain at the nexus of all UMMHC’s other initiatives. This is true from a business perspective, where interoperability is a key component of the hospital’s growth strategies, and from an “infrastructure-in-transition” perspective as old systems are replaced and new solutions incorporated. Information systems are being replaced at all five facilities with the Siemens Sorian solution, and this will be interoperable with Allscripts and other bright spots.

UMMHC also is implementing eWebHealth as the digital representation of its legal medical record. This system will be tightly coupled with current information systems, and will transition without interruption to new information systems as they are brought into production. The glue holding all of these initiatives together throughout the transition and into the future will be the Initiate EMPI solution and the dbMotion interoperability platform.

Each component of UMMHC’s information services strategy is integral to achieving the hospital’s goals, and they have been re-inforced at each step as staff evaluated options, selected vendors and secured approval.

George Brenckle, Ph.D., is senior vice president and chief information officer, and Richard Cramer is senior director for health information exchange and ambulatory integration, at UMass Memorial Health Care.