Health Information System Integration

Chapter 5 of 11

Information and Communication Technologies have made a considerable impact on the healthcare industry. Its adoption has dramatically transformed the way healthcare services are delivered or monitored; it will be on an ascending trajectory over the next few years as its forecasted market exceeds $379 billion by 2024.

However, the health information system in most developing countries is fragmented as many subsystems operate independently. Multiple initiatives to computerize health systems also exist, with each serving its own data need goals. Integration is an initiative to amend fragmentation. The integration of health care information systems has been a revolutionary effort to strengthen the quality of care by seeing to it that there is proper management of healthcare resources through information-based management systems.

The integration of health information technology into primary care includes an assortment of electronic methods that are employed to handle information about people’s health as well as health care, for groups of patients and individual patients as well. The use of IT can significantly improve the quality of healthcare and make it cost-effective.

5.1. DEFINITION

Health Information System Integration is the process of merging the components of different health information systems into one system. It aims to combine unconventional health computing and software applications within a healthcare organization and between two or more healthcare organizations to make them coordinate as a whole.

A health information system is overlapping, complementary, and interdependent. Given the large number of different information systems in the healthcare sector, it is not surprising that health information professionals are having a hard time creating a tighter integration system that will bridge the gap in the functionality of these various independent healthcare information systems.

In primary care, here are some examples of health information technology:

  • Computerized disease registries
  • Electronic prescribing
  • Clinical decision support
  • Automated provider order entry
  • Telehealth
  • Electronic medical record systems (EHRs, EMRs, and PHRs)
  • Consumer health IT applications

The Agency for Healthcare Research and Quality’s National Resource Center for Health IT function as the link between the health care community and the experts as well as researchers who were positioned at the frontlines of health IT. The following are health IT resources:

  • Health IT Tools and Resources
  • Workflow Assessment for Health IT Toolkit
  • Health IT Literacy Guide

5.1.1. TECHNOLOGY IN HEALTH CARE

Policies updated continuously as well as a physician/patient interaction stimulate the direction of treatment. There is no room for error in every one of these processes. As medical knowledge continues to expand day by day, the improvement of performance in the overall delivery of healthcare receives a lot of new emphases. Emerging technologies are, therefore, proving a useful tool in the pursuit of exhaustive efficiency.

Millions of dollars are invested in integrated health care management as well as electronic medical records per annum. These innovative capabilities empower medical staff with the power to manage and also share healthcare information as quickly as possible without any difficulty.

5.2. PURPOSE

Most modern operating rooms and intensive care units contain 50 to 100 different kinds of electronic equipment, yet most do not communicate or work efficiently in an integrated fashion. These limitations on equipment and technology often fail to improve productivity and reduce medical costs. The lack of healthcare integrated systems often leads to failure to identify deteriorating patients, diagnostic errors and inefficient work. As a result, healthcare providers work under stress and experience burnout.

Despite the increasing recognition of patient management risk in the healthcare system, the progress in patient care quality and safety has been relatively slow. The efforts exerted by healthcare providers to reduce potential harm to patients and to improve the quality of care often focus on a single or a collection of local interventions. The method is incremental and results only in modest improvements. Most improvements in the quality of healthcare often miss a more substantial opportunity to improve the procedure of healthcare itself. The adoption of systems integration incorporates fundamental building blocks of healthcare from clinical insights, equipment and technology.

5.3. HISTORY

Healthcare professionals across all specialties agree that effectively sharing information between machines, systems, and users is one of the essential factors in improving the efficiency, quality, and cost of patient care delivery. However, the inability to share information between different systems from different computer applications and different vendors has prevented healthcare information technology professionals from making significant progress.

Integrating the Healthcare Enterprise (IHE) is a multinational healthcare initiative that publishes domain-based internationally accepted implementation guides known as Technical Framework which allow established standards to undergo uniform implementation. This enables the seamless transmission of relevant health information from system and application, regardless of setting.

In 1985, the representing radiologists of the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) jointly developed and published Digital Imaging and Communications in Medicine (DICOM), a set of standards used for handling, printing, storing and transmitting medical imaging information. Initially, DICOM specified the type of hardware connection or interface that should be used to transfer image data to and from the imaging equipment. After taking this step, DICOM specified network operation protocols to facilitate a smoother transfer of image data.

From the late 1980s to mid-1990s, vendors started selling DICOM-compliant digital radiographic systems. The interoperability of these so-called DICOM-compliant machines was limited to specific point-to-point interfaces that required higher coordination between information systems.

In 1987, the Health Level Seven (HL7) Standard Development Organization (SDO) developed the consensus based HL7 Standard. This standard specified working interfaces for administrative and clinical structured data messages that allow disparate healthcare applications to exchange information.

To solve this dilemma the Healthcare Information Management Systems Society (HIMSS) and the Radiological Society of North America (RSNA) formally launched IHE.

Today, aside from radiology, IHE is expanding to other clinical areas, including pharmacy, medication management and clinical engineering. It is collaborating with medical specialists, IT experts, and other professional societies.

5.4. WHY HEALTH IT IS IMPORTANT

Health IT makes it practicable for healthcare providers to handle patient care effectively by securely using and sharing health information. By developing private and secure electronic health records electronically available where and when it is needed, health IT can significantly improve the quality of healthcare, thereby making it more cost-effective.

Health care providers, with the help of health IT, will be able to:

  • Have better chances at coordinating the care given. This is highly crucial, especially if the patient has a severe medical condition
  • They will have access to complete and accurate information about any patient’s overall health. This will, in turn, enable them to provide the best care within their means, whether during a medical emergency or a routine visit.
  • Have access to detailed information about a patient’s overall health, thereby helping with early diagnosis of the health problem, minimize medical errors, and also provide much safer care at incredibly lower costs
  • Serve as an excellent avenue to securely share relevant information with both patients as well as their family caregivers over the web, especially for patients that prefer this convenience. This implies that patients – and their families can actively participate in decision-making about their healthcare.

5.5. COMPONENTS
5.5.1. HEALTH INFORMATICS SERVICE ARCHITECTURE (HISA)

HISA is a standard that guides developers in creating modular open information technology systems by providing a formal basis for the service-oriented architecture required in health services.

5.5.2. PROCESSES

Health information system integration has two kinds of processes: First, the process needed to gather data from its sources and transform it into the right type of information. Healthcare providers can use this to analyze and make the right decision. Second, the process to determine which data requirements and solutions are needed for a project.

Many health information professionals mistakenly believe that the process of extracting, transforming, and loading (ETL) data sources are their silver bullet for developing useful applications in the healthcare sector. ETL is just one part of the process.

5.5.3. INTEGRATING HEALTHCARE ENTERPRISE (IHE)

IHE is an initiative of healthcare providers and the healthcare industry that aims to establish standards that will improve the way computer systems share healthcare information. IHE’s highest goal is to coordinate the existing standards such as HL7 and DICOM to meet the specific needs of clinicians in supporting optimal patient care.

5.5.4. RESOURCES AND SKILLS

Resources and skills are the often-overlooked components of healthcare information system integration. Experienced healthcare information professionals who understand data handling and healthcare workflow are necessary to have a complete process of health information system integration.

5.6. TOOLS AND TECHNIQUES
5.6.1. KAISER PERMANENTE MODEL

Kaiser Permanente is the most significant nongovernmental example of a fully integrated healthcare delivery system in the United States. It has more than 8.7 million members, 421 medical office buildings, 32 medical centers, 160,000 employees and 14,000 practicing doctors across nine states, including the District of Columbia.

The Kaiser Permanente-owned medical centers in California offer one-stop shopping for patients who want to avail services such as outpatient and inpatient management, pharmacy, radiology, surgery, laboratory, health education centers and other health procedures.

Kaiser Permanente is the only health plan located in California that has appeared for 11 consecutive years on the annual list of best health plans in the Pacific Region by the National Committee for Quality Assurance. Many economists and medical experts see Kaiser Permanente as a leader in quality healthcare.

Kaiser Permanente is a leader in information technology. It has been using computers to deliver healthcare innovations for decades. Since 2003, it has fully integrated its systems, giving its members access to its many online features. It has implemented HealthConnect, a secure integrated electronic data system that aims to link all aspects of care experience nationwide.

HealthConnect helps them in decision-making by providing them with practice guidelines, alerts and recommended medications. It also provides them with research information and measurement, including feedback from other practitioners and teams. HealthConnect gives members and patients online access to their medical records, test results, appointments, prescription refills and health education. They can email their physician with the system.

Ambulatory care facilities of Kaiser Permanente have complemented the implementation of HealthConnect. Since July 2008, almost half of Kaiser Permanente hospitals have been fully electronic. Kaiser Permanente physicians have been using computers in their examination offices, and more than 30 percent of its members have requested passwords to communicate with their doctors to access their medical records online.

Since most healthcare providers are new on the system, Kaiser Permanente learned the importance of backfilling for them to implement information technology. However, when healthcare providers learned the system, they found that they were equally productive while delivering a better quality of care to their patients. Most patients experienced better satisfaction due to Kaiser Permanente’s HealthConnect online features. Physician offices had a drop in the number of visits and phone calls. The statistics of redundant testing and imaging were observed, and tests are no longer lost once they are entered into the HealthConnect system. Overall, improved patient health outcomes were observed with Kaiser Permanente’s model of healthcare information system integration.

5.6.2. PROJECT MANAGEMENT INFORMATION SYSTEM (PMIS):

A project management information system (PMIS) is the comprehensive organization of information needed to execute a project successfully. PMIS is usually made up of one or more software applications combined with a systematic process for gathering and using project information.

Implementing change in an organization is often a complicated process. Project management is a standard guideline used to carry out project plans in different business sectors and is now an essential tool for implementing large-scale changes in healthcare.

5.6.3. HEALTH INFORMATION STANDARDS

Having an integrated patient information and management system enables a continuous flow that is cost-effective to the healthcare organization. This system minimizes the time needed to transmit information from the one sending the information to the department or practitioner who is waiting to receive it. A delay in the delivery of patient records and diagnostic results often cause bottlenecks in hospital and clinic waiting rooms.

The Integrated Healthcare Enterprise (IHE) paved the way for a comprehensive set of integration framework documentation that outlines the workflow of patient care in terms of information-exchange transactions and key integration points. Successful integration of electronic health record (EHR) can eliminate waiting time for the healthcare provider and patient. Participants in the care of the patient are empowered to make decisions and execute accurate healthcare management based on complete patient information and diagnostic results. With a fully integrated workflow in the clinical setting, minimized operating costs and optimized reimbursement of cost structure can be achieved.

5.7. FOUR COMPONENTS OF HEALTH IT INTEGRATION
5.7.1. CLINICAL LEADERSHIP

Change is somewhat difficult for everyone, but clinicians find it a bit tougher because they have to adopt new technology continually. This is where clinical leadership comes in. Committed clinical leadership is highly crucial and is heavily required to assist in navigating through the numerous changes in workflow and technology which usually accompanies health information technology integration. Traditional leadership – such as the Medical Executive Committee – may have to get involved in one way or the other, looking for leaders beyond this tight-knit group will significantly enhance success. Engaging or committed leaders who have a lot of backgrounds in the use of technology also adds credibility. It is a good thing to engage health IT experts as well as those who are average users but are in the leadership circle.

5.7.2. HEALTH IT GOVERNANCE

A well-grounded governance structure should be in place in order to address the numerous issues that are bound to arise in the course of both HIT adoption as well as optimization. Stakeholders need to be aware when it comes to how decisions are made. A clearly defined articulated process for change control should also be included along with governance. These governance processes should be accessible so that everyone in the organization can be aware and engaged. This helps in setting expectations appropriately as well as demonstrates the dynamic nature of HIT and the commitment to optimizing.

5.7.3. EXECUTIVE SUPPORT

Poor communication brings about major issues that prevent the achievement of objectives. It is crucial to develop an excellent and well-thought-out communication plan. Organizations are expected to adopt a standard, official mode of communication – which typically comes in the form of an email. This will help to create crystal-clear expectations for the transaction of quality information. This does not, however, rule out the use of other forms of communication. But in the end, consistent and effective communication results in participation and engagement.

The integration of health information systems – which include data and concepts in health services administered to patients – help in promoting health.

Integrated health information systems help healthcare providers to control or check a few health conditions such as obesity, hypertension, diet, and cholesterol level. By making use of information systems, providers can readily access the data of individuals from various levels of the health system. The information of clients flows throughout the healthcare sector via the use of integrated health information systems.

5.8. PREVENTION OF DISEASE

Information systems render assembly, analysis as well as dissemination of data that is necessary to guide, promote, and also evaluate both the disease prevention and health promotion programs.

Health information systems have been developed with the objective of integrating health information in order to meet consumer requirements, enhance care quality, contribute immensely to epidemiological research, minimize expenses, and also engender information management. Making use of standards and middleware results in systems integration subsequently leads to health promotion.

Standards on security, terminology as well as data exchange play a crucial role in integrating health information systems while providing interoperability across heterogeneous systems. Middleware is used in facilitating the integration of health information systems so that there will be no need to reproduce the same component when it comes to the interaction between the systems.

5.9. HEALTH INFORMATION SYSTEM INTEGRATION

System Integration, in general terms, can be referred to as the process that involves the connection of different components or subsystems into one, more extensive system which functions as one. In relation to software solutions, system integration is the process via which various IT systems are linked together along with services or software in order to enable them all to work functionally together.

Organizations rely on system integration to improve both productivities as well as the quality of their operations. System integration speeds up information flows and also minimizes operational costs for the establishment.

However, system integration is not limited to the internal connections within an organization but also involves third-party linkages that work toward the same goal with the parent organization.

System integration methods are typically divided into several categories:

5.9.1. VERTICAL INTEGRATION

In this system integration method, the subsystems or system components are incorporated by the creation of functional “silos,” and usually begin with the fundamental function upward. This is typically a straightforward method that involves a limited number of systems, though more than two.

The vertical integration method is not only rigid but also a bit difficult to manage over a relatively long term, every new function requires its own structural “silo.” This method can be effectively used for creating simple integrations that need to address only one function.

5.9.2. POINT-TO-POINT INTEGRATION

Also referred to as a point-to-point connection, this system integration method is not perceived as such in some quarters, and that is primarily because there are no more than two system components involved.

While point-to-point integration lacks the attribute of genuine system integration, it connects one system to another so that they can function as one.

Such a point-to-point connection typically manages one function and doesn’t involve complex business logic in any way. A lot of cloud-based apps out there render these types of system integrations as out-of-the-box, productized integration modules for conventional IT systems.

5.9.3. COMMON DATA FORMAT INTEGRATION

A common data format is a system integration method that is designed to prevent the action of every adapter from converting data from/to every other application’s formats. Integrating different IT systems generally requires that the data that is transmitted from one system needs to be converted to a different format i.e., the format that is used by the receiving system. The amount or number of data transformation will significantly increase, thereby becoming a high-maintenance task.

To overcome this undesirable challenge, a common data format approach can be employed. This allows one system to perform only one data conversion from its original format to the common, and the other way around as well. When this happens, the number of needed data transformations only remains as high as the number of subsystems.

5.9.4. HORIZONTAL INTEGRATION

Separate subsystems are used as common interface layers – referred to as ESB (Enterprise Service Bus) – between all subsystems. The horizontal integration method allows every subsystem to have no more than one interface to communicate with each of the other subsystems that are connected to the Enterprise Service Bus or common interface layer. The benefit of this system integration method is that every subsystem can be replaced or changed without necessarily re-doing the interfaces of all other systems.

5.10. INFORMATION SYSTEMS EVALUATION TOOLS

Healthcare information system evaluation tools have additional challenges compared to those in other organizations. The most striking difference lies in the use of more strict measurements of information systems in evaluating, leveraging improved treatment and care to impact patients’ lives, including the following:

  • User satisfaction
  • Individual impact
  • Organizational outcome

5.11. BEST PRACTICES

There is no “one size fits all” solution to integrating healthcare systems. However, guiding principles exist to help integrate efforts and achieve results.

5.11.1. PATIENT FOCUS

The most important goal for any healthcare system integration is to meet the needs of patients. Patients will actively resist every feature meant to improve their health status and communication with their healthcare provider if the providers fail to concentrate their efforts on patient satisfaction.

5.11.2. INTER-PROFESSIONAL TEAMS

One of the essential principles for healthcare system integration is an inter-professional team approach. All professionals working on a project should be considered equal. Professionalism should be maintained. Each team member should receive incentives for meeting efficiency and performance standards.

5.11.3. PERFORMANCE EVALUATION

The measuring and reporting of care outcomes are critical for successful health systems integration and should be performed on an ongoing basis. With a systematic and analytic approach, performance issues can reinforce organizational plans as well as high-quality, cost-effective, and patient-centered care.

5.11.4. EFFECTIVE TECHNOLOGY

High-caliber technology is critical for assessing patient information anywhere in the healthcare system and enabling communication between providers. Having a quality information system can enhance information workflow and communication between users, including the payers, consumers, and providers.

5.11.5. LEADERSHIP

Strong leadership is needed for the successful integration. A good leader can bring different organizational cultures together by ensuring that training and incentives are in place to facilitate successful adoption of information systems.

5.11.6. PHYSICIAN INTEGRATION

A strong physician system alignment is vital to achieving the best results in the design and implementation of health system integration. Physicians must consistently be involved at all levels, and they should embrace leadership roles to overcome barriers to healthcare systems integration.

5.11.7. STRUCTURE AND OVERSIGHT

Newly integrated healthcare systems information requires new governance structures. All stakeholder groups, including healthcare providers, must participate in achieving diversified governance. Accountability and structure for decision-making must be developed.

5.11.8. COMPREHENSIVE VISION

A truly integrated healthcare information system must cover all core services of health for the population. To achieve full systems integration in the healthcare sector, the focus must be on population health.

5.12. OUTCOMES

With successful healthcare information system integration, the following outcomes can be expected:

5.12.1. ORGANIZATIONAL AND OPERATIONAL

  • Improvement in productivity
  • Reduction of costs
  • Improvement in data quality, sharing and flow
  • Better data access and exchange
  • Improvement of data presentation
  • Reduction in medical errors

5.12.2. MANAGERIAL

  • Improvement in managerial control
  • Better understanding and controlling of different health system processes
  • Improvement in decision-making, allocation of resources, quality of care, work efficiency and performance
  • Better return of investment

5.12.3. STRATEGIC

  • More effective healthcare management planning
  • Increased synchronous collaboration among users and providers
  • Improvement in the relationship with suppliers
  • Improvement in the population’s health, quality of life and survival rates
  • Better process of knowledge sharing among healthcare practitioners

5.12.4. IT INFRASTRUCTURES

  • Better reusability of objects
  • Improvement in the use of e-healthcare and telemedicine-based patient support models
  • Achievement of non-invasive solutions
  • Improvement in process, object/component and data integration
  • Integration of systems and e-business solutions in the healthcare practice

5.13. CITATIONS

  1. Mathews, S. C., & Pronovost, P. J. (2011, March 2). The Need for Systems Integration in Health Care. Journal of the American Medical Association, Vol. 305, No. 9
  2. Ibid.
  3. Ibid.
  4. Engel, K., Blobel, B., & Pharow, P. (2006). Standards for Enabling Health Informatics Interoperability. Studies in health technology and informatics, 124:145-50
  5. Sherman, R. (2003, October 1). Five Essential Components of a Data Integration Framework. Information Management.
  6. Integrating the Healthcare Enterprise (IHE) (2015). In IHE. Retrieved July 20, 2015.
  7. Op. Cit. Sherman
  8. Porter, M., & Kellogg, M. (2008). Kaiser Permanente: an integrated health care experience. Revista de Innovación Sanitaria y Atención;1(1):1-8.
  9. Chittick, P.K., & Persaud, D.D. (2001). Project Management: An Essential Tool for Implementing Integrated Information Technology. Healthcare Management Forum. Volume 14, Issue 4, Winter 2001, pp 1-7.
  10. SigmaCare (2016). The Role of Clinical Decision Support and Analytics In Improving Long-Term Care Outcomes. White Paper.
  11. Op. Cit. Monteiro
  12. Mantzana, V., & Themistocleous, M. (2004). Identifying and Classifying Benefits of Integrated Healthcare Systems Using an Actor-Oriented Approach. Journal of Computing and Information Technology, 265-278.