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System-wide EHR integration limits flexibility in care

Health care providers want one IT tool to satisfy all their needs. But full EHR integration might not be worth the trouble.

The Everett Clinic, a physician group practice in Snohomish County, Wash., uses the same technology vendor for a number of applications. The practice contracted with Epic Corp. to supply its electronic health record (EHR), registration, scheduling, billing, radiology and health information management systems. The clinic also uses a few web applications supplied by Epic as part of a system-wide EHR integration.

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Melanie Vance, the clinic's Epic director, said the ability to use a single vendor as a one-stop-shop for all these different functions was a major selling point. All the systems harmonize well and when information is changed in one component, such as the EHR, it is automatically updated throughout the entire system, including in billing software, she said. This is because all systems run on the same database.

"To have everything in a single data base, there's just great benefit. There are a lot of advantages to having everything in one system," Vance said.

This sentiment is shared by many in health care today. A KLAS report released in August showed providers are increasingly moving to EHR vendors like Epic and Cerner Corp. that promise system-wide EHR integration and away from other vendors that may require the implementation of multiple components.

But while opting for a fully integrated EHR system may represent conventional wisdom, some in the health IT community are starting to question the sagacity of this approach. A unified infrastructure may offer some advantages, but it may cause some headaches as well.

Integration versus best of breed

As Vance described, the main advantage of going with a fully integrated EHR system is that information lives in just one place. This means various components of a provider's IT infrastructure can make use of data in a seamless way. Also, since everything is modular, it is relatively easy to turn on new components. But just because integrated components use data efficiently and can be simple to set up doesn't always mean that those components are the best match for a provider's needs.

Kenneth Mandl, M.D., a physician and researcher at Harvard Medical School at Boston Children's Hospital, said EHR vendors that offer complete solutions typically design systems from the ground up. This approach requires each of the hundreds of EHR companies to redevelop every aspect of the software, including some basic functions like word processing or text search.

Tech companies have offered that kind of functionality in standalone formats for years, and the idea that an EHR vendor could develop word processing capabilities comparable to Microsoft Word or text search on par with Google is unrealistic, Mandl said.

There are many companies that promise you the world. The reality is a little different.

Luis Kun, IEEE Computer Science Society Board of Governors

"What our children are using is more advanced and evolves much more rapidly" than components of EHR systems, Mandl said. "EHRs have improved incrementally at best."

Luis Kun, member of the IEEE Computer Science Society Board of Governors and founder of the organization's USA Electronic Health Record and High-Performance Computers Working Group, agrees. He said that there are many vendors who have useful applications. Some may offer advanced EHRs, others may specialize in practice management, while still others provide the best patient portals. But no one vendor has the best applications in all these areas, he said.

"You have many vendors that claim to have lots of functionality when in reality they do not have it," Kun said. "There are many companies that promise you the world. The reality is a little different."

Front-end EHR integration creates back-end technical issues

The idea behind integrating health care provider's IT processes into a single system is to give physicians and other data users a simplified user experience. This approach may work out well for doctors, but it can make life difficult for technical staff.

John Robles, an Epic implementation specialist who recently completed an installation at the University of Arizona Health Network, said vendors sell their unified systems as being a simple way for medical offices to get EHRs, practice management and laboratory information systems up and running. But things don't always work out this way.

"People think all you have to do is turn a knob," Robles said. "No, it's not that easy."

The hard part comes when IT staff need to set up unified databases to serve several different applications or configure components for the medical office's specific needs, Robles said. These tasks require a lot of back-end work that providers may not be prepared for because they thought their integrated EHR system would be simpler to install.

Furthermore, he described the back end of systems as being "noisy" and said making a minor tweak to the user interface may require the alteration of substantial sections of code. These changes may have additional unintended consequences.

Robles said that vendors will typically work with practices to resolve these issues, but they often charge extra fees. This can add millions of dollars to the cost of a large implementation.

Let us know what you think about the story; email Ed Burns, News Writeror contact @EdBurnsTT on Twitter.

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