"In 1980, 10 million Americans were enrolled in a Health Maintenance Organization (HMO). However in 1995, 60 million Americans received their health care services through HMO's. Nationally, more than one in five Americans (58.2 million) are now enrolled in HMO's" (VAHMO, 1995). The health care industry's gradual shift from fee for service to HMO's was sparked by the desire to reduce the cost of medical care. HMO's are now common place in the health care market. Humana, Pacificare and Kaiser are just three of the ever expanding HMO conglomerate. HMO's give consumers an opportunity to "reduce their out of pocket cost and subsidize their fitness expenditure. For an HMO to compete with it's competitors they need to develop new capabilities to compete" (Mulkerrin, 5).
Kaiser Permanente of Ohio envisioned reducing the cost of medical records keeping while improving access to patient records. "The Cleveland based HMO had built an enterprise-wide electronic medical record system which supported its quality and business needs, and then looked for assistance to expand the systems functionality to replace the paper chart"(Microsoft, 1997).
In this proposal we will examine a computer based medical records system, which will:
Kaiser can eliminate most of its medical record problems through careful selection of a software vendor.
Established in 1964, Kaiser Permanente of Ohio provides comprehensive medical and hospital services to approximately 203,500 members in the greater Cleveland and Akron markets. The HMO prides itself on earning a three-year accreditation from the National Committee for Quality Assurance (NCQA).
Kaiser Permanente serves approximately 172,200 members in Cleveland and 31,300 members in the greater Akron/Canton market through the Ohio Permanente Medical Group with 210 physicians as well as 800 affiliated community-based physicians in our service area.
In 1997, Kaiser Permanente and the Ohio State Medical Association joined together to support the Physician-Health Plan Partnership Act, a precedent -setting alliance uniting Ohio's 15,000 member physician trade association and the Ohio market of the nation's largest and oldest group practice prepayment health plan. The Physician-Health Plan Partnership Act adopts the best practices of health plans as the basis for industry standards for the state of Ohio (Kaiser, 1998).
Kaiser Permanente of Ohio has 12 medical offices in Metropolitan Cleveland and Akron, 220 physicians, 100 allied health providers and an estimated 1.3 million patient encounters in 1997, Kaiser needs to manage over 6 million patient records (Microsoft, 1997).
Maintaining medical records is both expensive and time consuming. HMOs who have an expanding customer base will have to determine an efficient and cost effective way to handle patient records. Kaiser Permanente of Ohio has already attempted to make accommodations to handle their medical records. "Rather than selecting the strongest software application and then tailoring its business process to the application, the Cleveland based HMO developed its own clinical system which supported its quality and business needs and sought to expand the system's functionality to replace the paper chart" (Microsoft, 1997).
Kaiser of Ohio has several design obstacles, which a vendor's system will need to overcome:
* The system will need to be able to be designed around Kaiser' existing system.Kaiser of Ohio is an established HMO which handles over 6 million patient records. If Kaiser chooses a vendor who does not have the capability to integrate around their system they could stand to lose a substantial part of their revenues. The cost and loss of time in training employees and possible patient record displacement are just a few of the problems Kaiser could face if they chose a vendor that does not meet their current system needs.
* The system must have the capability to retain standard policies, procedures and forms.Implementing a system, which does not retain Kaiser's policies, procedures and forms could cause the HMO to lose its long-standing accreditation with the National Committee for Quality Assurance (NCQA).
NCQA is the major accreditation body for managed care organizations (MCO). It is an independent organization that works with the managed care industry, health care purchasers, health care researchers and consumers to develop standards that measure the structure function and functions of MCO quality improvement programs. The standards for MCO accreditation are set in six areas:
NCQA reviewers look for consistent and complete documentation in medical records in addition to over 20 essential components of quality patient care. Components include:
Making the transition from paper charts to electronical medical records could disrupt normal communications in the healthcare patient-medical records transaction. The vendor system should be able to maintain and manage policies, procedures and forms across the continua of care.
* The system should allow the HMO improve accessibility and reduce the cost associated with medical records keepingMedical records maintenance is expensive. Costs include storage fees, data retrieval time, updating and replacing medical records. Kaiser of Ohio may save money and improve accessibility with computer-based patient records.
Kaiser's attempt to have greater accessibility to patient records will shift the organization's paradigm from dependence on written material to trusting computer-based information. The use of information technology to link patient records in Permanente of Ohio will create a seamless flow of communication between the providers and the patients.
In selecting vendors to research for the report, we chose three that met the immediate CPR needs of Kaiser Permanente of Ohio. Kaiser's current needs include implementing a CPR system that integrates easily with its existing systems, meets the standards of policies, procedures and forms, and reduces medical record keeping costs. In addition, vendor selection was based on significant criteria that healthcare organizations specified in the 1997 HIMSS/Hewlett-Packard Leadership Survey Results in the April 1997 issue of Healthcare Informatics.
We decided to discuss the specifics of computerized patient records (CPR) software from Sequoia Software, HealthPoint, and Epic Systems. The information we gathered on the vendors came from worldwide web pages and personal telephone interviews.
Other pertinent selection criteria for choosing a CPR system came from 1,220 survey respondents. According to the survey, the second most important application priority within individual organizations was to implement an electronic medical record system within the next year. Healthcare organizations also claimed that the top futuristic healthcare technology that they hope will develop over the next five years is access to medical records via the Internet. In addition, the top three clinical forces that are currently driving computerization within the organization are the need to automate patient records, the need for comparative outcome data and the need to provide decision support capability to caregivers. On the other hand, the primary roadblock to CPR implementation is the cost of integrating software packages from different vendors. Sixty-five percent of healthcare organizations listed HL7 standards as the most important standard to follow when considering new IT software purchases. Next, twenty-four percent of respondents said that electronic medical record keeping is the top IT solution that must be available one hundred percent of the time in their organizations. The top solution was maintening general clinical systems. Finally, we looked for a high level of system and user security in the software selection process because it is a national healthcare IT topic of interest.
As a result of the survey results and the current needs of Kaiser Permanente of Ohio, we carefully examined the three vendors, considering all of the above criteria before deciding on a software vendor and making implementation recommendations.
Founded in 1979, Epic Systems is a national leader in building healthcare software solutions. Over the past 5 years, its human resources have increased 40-70% and its revenues by 1100%.
Epic was the first company of its kind to deliver a Windows-based CPR System. Later on, it created several other integrated software packages for managed care, appointment scheduling and patient accounting. Its clients include integrated delivery systems, managed care organizations, medical groups and hospitals with large ambulatory care environments. Epic's mission is: Do well. Make money. Have fun. Headquarters: Madison, WI
HealthPointHealthPoint is in business to make affordable tools to manage clinical information. It is a joint venture between Physician Computer Network, an expert in managing clinical information, and Glaxo Wellcome, the largest international research-based pharmaceutical company. HealthPoint's mission is: To improve the quality, efficiency and cost effectiveness of healthcare delivery by providing state-of-the-art information management and communication services to providers patients, payers and suppliers. HealthPoint was formed to meet market demands of cost containment, complicated treatment protocols and to improve the quality of healthcare through information technology solutions. It's initial product, HealthPoint ACS (Advanced Clinical System) was first developed ten years ago by medical experts and technicians. ACS integrates patient clinical information with health plan requirements, treatment protocols and a drug interaction database. Headquarters: Cary, NC
Sequoia Software Corp.Anil Sethi, a Hopkins-trained biomedical engineer, and Mark Wesker, a healthcare attorney, formed Sequoia Software in 1992. Sethi had previous market experience from Apple and Hewlett Packard. Four years later, Rick Faint was brought on as its CEO, who had successful experience in managing venture-backed enterprises, one later becoming an IPO. Sequoia received the 1997 Nicholas E. Davies Award from the Computerized Patient Record Institute and the 1997 Industry Solution Award for Clinical/Patient Information Systems in the Managed Care category from Microsoft.
Sequoia focuses on developing enterprise-wide transaction services in healthcare. Its electronic patient record product, Medstar, is Internet interfaced and can be accessed from nearly any operating system. Such an interface can be adapted to reflect methods of clinical data collection by physicians is highly distributed and is capable of linking different brands of software applications from multiple vendors. Headquarters: Columbia, MD
General Information:
Epic Systems is known to be the first company to create a Windows-based computerized patient medical record system in the industry to service large healthcare organizations. Epic began developing the text-based system in 1979, but developed a new system for a Windows environment 12 years later. This development was coincident with a drop in the price of workstations with the ability to display graphical user interfaces. EpicCare was released in 1993.
Today, EpicCare services 800 providers' nationwide and 13,000 licensed users, most of which are from multi-site ambulatory care environments. Its main purpose is to re-engineer the management of patient care to reduce costs and achieve a better quality of care previous to its implementation. Providers can computerize patient charts, order tests, write prescriptions, review test results, make referrals and document patient visits. EpicCare has built-in alerts to inform the physician about certain factors of a patient's health, such as drug allergies.
EpicCare's CPR components include: patient histories, visit documentation, document imaging support, health maintenance management, medications management, order entry and communications, results reporting, referral management, powerful chart review, alerts, electronic messaging, clinical guidelines, clinical data repository, and more. EpicCare also provides powerful analysis tools for HEDIS and outcome reporting.
Data integration:
All of Epic's products are integrated. These include EpicCare for computerized patient records, Tapestry for managed care operations, Cadence for appointment scheduling systems, Resolute for patient accounting, and EpicLink, which permits user access via a web browser to all of the integrated software systems.
Technical Environment:
Thousands of users can access and update EpicCare simultaneously. An entire integrated Epic software system can take up to tens of Gigabytes of space in a healthcare information system, but figure was not found for the specific space for EpicCare standalone. EpicCare is a relational database and is also part of a relational database model of all Epic Products. In addition, it complies with industry standards of Open Database Connectivity (ODBC). EpicCare is not only an open system but operates in a Wide Area Network, such that healthcare providers in different locations may access and update system information. EpicCare is built for a client/server information system model, where clients can be machines with MS Windows, Windows 95 and Windows NT operation systems. Its servers are UNIX, VMS and Windows NT, just to name a few. For the most part, EpicCare is platform independent like other Epic products. IBM, Digital, HP, Sun DG, Sequent and many other platforms work well with EpicCare. EpicCare complies with industry-standard EDI, such as HL7, ASTM, ANSI X.12 and other interface engines. EpicCare and other corporate products are programmed in the object-oriented language called M.
EpicCare is claimed to be easy to use by providers and Epic employees. Standard Simple Query Language (SQL) querying is at the fingertips of the user and can produce reports such as the number of medications prescribed per physician for a given illness in a set time period. EpicCare uses a graphical user interface, making it easy to learn and use. A help button is easily accessible on the desktop when running the software.
System Security:
There are several ways to monitor security within the system. There are assigned codes for each user and for each level of access from extremely restrictive with 1 user to system-wide access. Some Epic customers may even use fingerprints to allow system access. Less-restrictive access is user-defined and individually customized. There are also checks in the system that automatically logs off users who leave an unattended computer. In sum, there are multiple levels of security and they are adaptable to organizational needs.
Vendor Support:
While it is difficult to pinpoint a set amount of time for training and consultation, there are 3 levels of training for a given client. The first level targets getting the IT managers from a given organization up to speed with the software. The second level focuses on these individuals educating their staff. The third level is user communication with Epic for further assistance. Each level of training is dispersed in time frames of two weeks at a time, lasting about 3 of 5 weekdays. Overall there is no set length of training. Unfortunately, I was unable to gather any cost information in talking with representatives from Epic. However, I learned that the cost of training is often summed in with the entire software purchase contract, instead of being a separate cost. If the person seeking consultation has gone through level 1 of the training, Epic does not charge for telephone consultations. If the amount of help needed involves having an Epic technical person on site, the client is told up-front what the charge will be. In addition, there is no limit on the amount of training for a user. Support is offered in terms of training, maintenance, help desk and technical support. Epic has a 24-7 help line such that someone will answer the telephone from 8 AM-8 PM weekdays and from 8 AM-5 PM on weekends. During off-hours, an on-call person can be paged though voice mail left by a customer.
HealthPoint: HealthPoint ACS&trade (Advanced Clinical System)
General Information:
HealthPoint is a joint venture between Glaxo Wellcome and Physician Computer Network (PCN) and by pioneering the use of financial management and clinical information systems in medical offices, has become the leading provider of information systems for physicians in the United States. Ten years in development by medical experts and technicians, HealthPoint ACS makes it possible for practitioners to integrate information required for clinical decision-making history, treatment protocols, formulary and health plan requirements, patient education information, and drug interaction databases at the point of care. More than 70 clinics, group practices and academic centers throughout the U.S. have purchased HealthPoint ACS through HealthPoint's national network of quality value-added resellers. The system allows access to the complete medical record, while enabling point of care documentation, providing office and business-related efficiencies, and creating the ability for physicians to analyze their medical practice so they can better understand how to manage their patients' health. HealthPoint ACS provides easy-to-use tools for physicians and other healthcare providers to use to document clinical encounters, monitor and improve workflow, and conduct practice analysis. By providing the ability to quickly access and record comprehensive patient and health plan information at the point of care, the product helps ensure accurate, complete and legible medical records and facilitates the delivery of quality patient care. HealthPoint ACS runs on a variety of hardware platforms and incorporates point and click technology to minimize typing. HealthPoint ACS(TM), is being used to create the first-of-its-kind national observational database on clinical, economic, humanistic, and epidemiological outcomes in-patients with HIV and AIDS. The database, which protects patient confidentiality by removal of patient identifiers, will provide the most comprehensive information of any such HIV database available. This database is expected to become a premier disease management data source for HIV/AIDS. From encounter notes to workflow management to practice analysis, Healthpoint ACS helps keep a practice on a prescribed course.
Data Integration:
There appears to be unique data integration but the different applications could not be ascertained through this source of information.
Technical Environment:
The HealthPoint ACS software can be used on a variety of hardware including PCs, flat screen monitors, wireless portable pen computers, as well as "thin clients" or less powerful computers using Citrix WinFrame® thin-client server software. The company embraces an open architecture philosophy that supports use of existing systems to save resources and avoid duplicating information entry. HealthPoint has developed standard and custom interfaces to the nation's leading practice management systems (PMS) including PCN® Health Network(TM), VERSYSS® MENDS ICF(TM), Wismer Martin Sm*rt® Practice, The Medical Manager®, MDS Technologies MD-SERVE(TM), and IDX's and Cycare's PMS. These interfaces allow the clinical and financial systems to share data such as patient demographics, scheduling, and billing.
These PMS systems together represent more than three quarters of the ambulatory care PMS market. Additionally, interfaces to allow connectivity to the leading reference laboratories are now completing beta testing, and interfaces to two of the leading interface engines are in production at customer sites. HealthPoint's interfaces comply with current healthcare application and communication standards, including HL7, ASTM and TCP/IP. The system is based on client server architecture and is written in C and C++. The operating system is Window-based and is designed to work on Microsoft work-group for Windows and others. The medical record information resides on a local area network server with hardware that is IBM/PC compatible. Connectivity to other systems is handled through standard industry protocols and the system allows patient records to be reviewed and updated from any site. The database is relational and conforms to industry standards of open database connectivity (ODBC). ACS supports business and clinical decisions based on reports generated from a structured Oracle database. It incorporates client server, Microsoft Windows, and hand held pen-based technology. ACS has the ability to integrate with existing office systems to link clinical and billing information.
Systems Security:
Security and confidentiality is handled through a series of passwords and data encryptions. Users are assigned specific codes for each level of access. There is automatic log-off for users who leave the terminals unattended, and for incorrect password entries.
Vendor Support Tools:
The use of the software involves training an on-site IT manager who then trains the staffs and can refer back to HealthPoint for assistance when necessary. Healthpoint ACS has 24-hour, 7 day-a-week phone support with management support by local office representatives, software upgrades and routine enhancement releases.
General Information:
Sequoia's Software Corporation provides health care specific products and tools built on Internet technology that enable health care organizations to capture, archive, and access information from a variety of distributed sources. It is this technology that empowers health care organizations to: (1) gather clinical data and create an electronic medical record without changing the way physician's record clinical information; (2) link disparate software applications so that information can be accessed by authorized users from a simple Browser interface; and (3) can operate in a highly distributed environment where geographically and organizationally distinct health care facilities must access and share patient information (Sequoia, 1998).
Data Integration:
Sequoia's products are designed to enable health care organizations and health care technology vendors to add value to their existing technical infrastructure and applications through use of Transaction Services developed specifically for health care. Healthcare Transaction Servers are a set of "back office" technology services for developing, maintaining, transferring and accessing records generated by disparate applications in a distributed, heterogeneous health care delivery network (Sequoia, 1998).
Technical Environment:
Medstar is constructed to be embedded behind other applications. They are best described as back office server suites consisting of transaction-oriented components. These components are in Microsoft terms; a suite of "LOBjects" (Line of Business Objects) designed for healthcare's "plumbing" needs (Sequoia, 1998).
System Security:
Medstar has proven to provide secure seamless and instantaneous access to massively distributed medical records across a statewide Intra-delivery network (Sequoia, 1998).
Vendor Support:
Training is usually from 6-9 months after a system is implemented. Sequoia trains the management level employees, in order to give them superior knowledge of how the system works. They also provide training to staff level employees.
The initial cost of the system in a lump sum (this amount includes training, system implementation, etc.) can range from $150,000-$250,000. Support is generally from 8 AM-5 PM. After hours, a Sequoia representative usually carries a pager in order to provide users with 24-hour service.
|
Criteria |
HealthPoint - Advanced Clinical System (ACS) |
Epic Systems - EpicCare |
Sequoia Software - Medstar |
Easy to Use |
*** |
*** |
*** |
Graphic User Interface Used |
Y |
Y |
Y |
Windows-Based |
Y |
Y |
Y |
|
On-screen Help Command |
Y |
Y |
Y |
|
Can be Interfaced with other Products |
Y |
Y |
Y |
Package Costs |
$25,000-$35,000 |
N/A |
$50,000-250,000 |
Hours of Help Line Availability |
*** |
*** |
*** |
Generate Electronic Forms |
*** |
*** |
*** |
|
Allows Simultaneous User Access |
*** |
*** |
*** |
Has Security Components |
*** |
*** |
*** |
Ease of Information Access |
*** |
*** |
*** |
|
Support breadth of Healthcare Domain |
*** |
** |
*** |
|
Decision Support Capabilities |
*** |
*** |
N/A |
|
Built-in Clinical Pathways |
*** |
*** |
N/A |
|
Storage and Retrieval of Images |
* |
*** |
*** |
Preventative Care Alerts |
*** |
*** |
N/A |
Key to levels of Product Performance:
* = Low Coverage
The deciding factors for choosing a system for Kaiser of Ohio were hard to decipher. Most of our phone interviews were incomplete due to either the companies' reluctance to answering the question or the interviewers' reluctance to ask the question. Also, a limited amount of information could be gathered from the web. All systems show a strong functionality in user friendliness, vendor support and data management. Exact cost data were difficult to obtain. Some vendors have a flat rate while others have a per user cost. We recommend that Kaiser of Ohio request each vendor to send a representative to his or her site to who can:
Dick, Richard, and Steen, Elaine. "The computer based patient record; An essential technology for health care". Division of healthcare services institute of medicine.
http://www.nap.edu/readingroom/books/computer
Epic (1998). "Epic Care; Epic's Integrated Software." http://www.epicsys.com/html
Epic Systems Corporation (1996). "The power to perform the freedom to change".
Health Information and Management Systems Society. "Back to Basics". Healthcare Informatics April 1997: pg. (SS1-SS16)
Health Point (1998). "Product Overview". http://www.healthpoint.com/
Kaiser Permanente of Ohio (1998). Kaiser Permanente "Cleveland and Akron Markets". http://www.Kaiperm.org/locations/ohio.html
Microsoft (1997). "Healthcare solutions on the Windows NT platform". Volume 16. Washington: #098-69454 pg. S-11.
Mischler, Nicholas, M.D., & Quinn Nancy, RN "National Committee for Quality Assurance Accreditation: Research Report". Pg. (1-10). http://www2.milliman.com/milliman/publlications/reports/ncqa_accreditation/toc.html
Mulkerrin, Paul. (1995). "What will create value in managed care?" Advest Healthcare Review pp.5-9.
Sequoia (1998). About Sequoia; Products and Service. http://www.sequoia.com/html
Virginia Association of Health Maintenance Organizations (1995). "Growth of HMO Enrollment on National Level". http://www.va-business.com/eletro/hmos/region.html
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Rema Padman, rpadman@andrew.cmu.edu