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17

Special-Purpose Software

James M. Walker and Michael J. Komar

The rationale for special-purpose software to supplement the core EHR is compelling:

There are many critical clinical processes that no general EHR software is (or soon will be) able to support effectively. (One example is integrated sub-systems for simul- taneously documenting and coding procedures while capturing and labelling the asso- ciated images.) Unfortunately, most special-purpose software ends up costing an organization far more than is ever realized in benefits—financial or clinical. This chapter discusses methods for integrating special-purpose software with your core EHR in ways that will increase your odds of completing successful individual projects and of constructing an integrated, cost-effective EHR.

The Setting

Requests for special-purpose software almost invariably arise out of user dissatisfac- tion with the existing EHR. Frequently this dissatisfaction is the result of a “plain vanilla” implementation of the EHR that does not take adequate account of the work- flows and information needs of specific user groups. Dissatisfaction may also stem from user ignorance of the functions available in the organization’s currently implemented EHR. So requests for special-purpose software offer your team an opportunity to check the adequacy of your implementation and your training efforts—and to refine them both.

Another frequent cause of dissatisfaction with the EHR is the fact that many clini- cal information management needs go beyond the current (and sometimes develop- mental) scope of the EHR. This is an area where an effective partnership with your EHR vendor is critical. You need them to be organized enough to know what func- tions they plan to deliver and when—and honest enough to tell you. And you need them to deliver on schedule. Having a clear sense of whether and when new functions will be available is critical to making the business case for special-purpose software. If the new function will be available in six months, special-purpose software could not be selected and implemented in a shorter time frame. If the vendor has no plans to develop the function, it is a simple matter of estimating benefits and costs.

Another source of dissatisfaction arises out of EHRs’ remarkable effectiveness at what they do well. Because of their high performance, users (as well as informaticians) may have trouble distinguishing between what is feasible (given inevitable resource constraints and organizational priorities), what is possible (in the absence of con- straints), and what can as yet only be imagined.

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Finally, special-purpose software may appear to be a better bargain than it is because many of the costs of a successful implementation are hidden from the customers. It is a rare sales presentation that includes any mention of the need for (or cost of) such critical project components as the needs assessment, process re-design, building and maintaining multiple electronic interfaces to other information systems, and plan- ning for data security and confidentiality. Educating your internal customers regarding these considerations is a difficult, but critical, element of managing special-purpose software effectively. A written policy ratified and consistently enforced by senior clinical and operational leadership is a critical first step in the educational process. (See Appendix 12 for an example.)

Avoiding Chaos

It should be no surprise that special-purpose software strikes many clinicians and even some managers as a panacea. As opposed to the usual compromises among different stakeholders and the wait for implementation (or enhancement) of the core EHR, special-purpose software promises a rapid, focused solution to the needs of a specific set of users. But, while this narrow focus is the reason that special-purpose software exists, it has the potential to create chaos. This is because connectivity is critical to infor- mation system effectiveness. In the same way that a personally optimized telephone would be useless if it did not connect to the standard telephone system, special-purpose software—however perfectly designed for its users—must connect seamlessly to other information systems (e.g., EHR, laboratory, image management, scheduling, registra- tion) to be usable. This is the main reason that most special-purpose software does not end up being used—even by the individuals who select it.

Understandably, connectivity seems relatively unimportant to users who request special-purpose software. They feel their own immediate needs vividly. They are unlikely to understand the importance of connectivity until, for example, multiple data- bases make creating a report difficult and expensive. In fact, it is often their customers (particularly other clinicians) who find the lack of connectivity between the special- purpose software and the core EHR unacceptable. For example, they may be mystified and impatient when echocardiography reports are not available in the EHR.

Lack of connectivity has multiple implications. The first is fragmentation of the EHR.

For example, if colonoscopy results are not transmitted to the EHR, clinical-decision support to remind clinicians of a patient’s need for colon cancer screening will be unworkable. Producing reports on the organization’s performance on colon cancer screening will require accessing multiple databases, increasing the cost (or decreasing the quality and number) of reports that can be produced.

An obvious way to increase connectivity is to build electronic interfaces among infor-

mation systems. Unfortunately, interfaces are unpredictably difficult and expensive to

build and to maintain. As Clem McDonald, a leading EHR designer, implementer, and

researcher observes, “These many different and cubby-holed systems present an enor-

mous entropy barrier to the joining of patient data from many source systems in a

single EHR. The work required in overcoming this entropy by interfacing to the many

different islands and regularizing the data they contain has been more than most can

afford. Medical data does not generate spontaneously within the medical record. It all

comes from sources elsewhere in the world, and all of the obstacles and most of the

work of creating an EHR relate to these external data sources and the transfer of their

data into the EHR.”

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Figure 17.1 illustrates the way that non-interfaced, multiple clinical information systems require repeated performance of the same task, for example, entry of the patient registration.

Another hidden cost of special-purpose software is associated with “bullet-proofing”

the system. Reducing downtime to an acceptable minimum, creating and testing a dis- aster recovery plan, and providing adequate information security are expensive of money and human resources. External regulations are not negotiable, but CDOs often make an implicit decision to operate such systems without effective fault tolerance and disaster recovery plans—a fact that users are typically unaware of until disaster strikes.

Reg Reg Reg

Reg

Reg Reg

Reg Reg

Reg Reg

Reg

Reg

DB DB DB

DB DB

DB

DB DB

DB

DB

DB

Billing Billing Billing

Billing Billing

Billing Billing

Billing

Billing Billing

F

IGURE

17.1. Multiple information systems with large numbers of redundant functions within a disorganized healthcare environment. The box represents the healthcare system, while each disc representing a self-contained information system with its own discreet functions: scheduling, lab- oratory, radiology etc. (DB = database, Reg = registration)

Special-Purpose Software and Confidential Address

You have invested substantial resources to assure that your core registration system protects patient confidentiality. One element of this protection is a place to record a patient’s confidential address. However, a special-purpose applica- tion may not contain a confidential address field, exposing the organization to liability for failure to comply with the patients’ request that you use their con- fidential address. Users of applications without interfaces from one of your core registration systems must consider the following questions:

Is the application ever used to register patients?

Is the patient ever contacted directly (by mail or phone) using the address or phone number stored in the application?

If yes, how will you accommodate patient requests that you use a confidential

address or phone number?

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Finally, implementing special-purpose software may delay the implementation and post-implementation optimization of the core EHR by draining away scarce human and financial resources from the core project. (Alternatively, it may give the organiza- tion one of the small wins that sustains the larger project.) More subtly, widespread use of special-purpose software can persuade the organization that specialized soft- ware and electronic interfaces are adequate substitutes for the organizational negotia- tion and process standardization that improved care quality and efficiency usually require.

Integrating Special-Purpose Software

Despite the risks that special-purpose-software systems carry with them, the answer is not to eliminate them, but rather to create a portfolio of software that meets your orga- nization’s needs.

The first step is to base your core EHR implementation on an organizationally agreed, prioritized list of clinical business needs. As you work down this priority list, your team will likely identify high priority needs that your core EHR vendor does not plan to support, at least not soon enough to meet your needs. Working this way, you will spend your implementation resources on the most strategic opportunities, whether core or special-purpose.

Of course, however closely you adhere to this principle, parts of your organization will undoubtedly follow the usual method of selecting special-purpose software: A physician will see a software demonstration at a national meeting and decide that it is the solution to a pressing need.

The problems with this method are many:

• The software may not do what the demonstration promised or implied it would.

• The software may be difficult to link to the core EHR.

• Even if the software works as promised, it may require extensive re-design of current workflows, with resulting organizational redesign costs.

• Since the demo didn’t start with the organization’s needs, it is unlikely that the orga- nization’s needs will be met—even by a “successful” project. (Or as Yogi Berra said,

“If you don’t know where you’re going, you’re likely to end up somewhere else.”)

• Other users (e.g., pediatric cardiologists) will request a different, but essentially similar, software system because this one (e.g., chosen by adult cardiologists) does not meet their needs.

• The costs of the project will exceed expectations.

• Multiple electronic interfaces will be required. At least one will involve months of trying to get two prominent vendors to cooperate with your technical team.

Best Practice

Whether the EHR project team identifies a strategic need that will be unmet by the core EHR or a special-purpose software system is proposed by a user, the same process will increase the odds of the project producing measurable benefit to the organization.

• Needs Assessment—The first step is to document the needs that the special-purpose

software will address. (See Chapter 2.) In the case of special-purpose software, it is

particularly important to balance the needs of the practice (typically for increased

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local quality, efficiency, and profitability) with the organization as a whole (typically for improved service to internal and external customers and net financial benefit to the organization). It is also vital to ensure that all potential stakeholders have been consulted regarding their needs (e.g., pediatric and adult subspecialties, or multiple practices).

• Executive Confirmation—Executive leadership determines where the needs fit on IT’s priority list. They also confirm that all relevant stakeholders have been included in the needs analysis.

• Gap Analysis—Identify the needs that cannot currently be met by the core EHR (and related software) and estimate when the needs will be met.

• Market Assessment—Assess special-purpose software products for their ability to meet the documented needs. Assess potential vendors for financial viability, for their likely longevity in the market, for their technical capability, and for their commit- ment to quality and customer service. We use well-known healthcare IT consultants to assess market viability, but since most of the vendors in question are small, new, and privately held, we have rarely gotten information that aided our final decision.

For the market analysis, our most effective tool is a telephone conference call with current customers, supplemented by selective site visits. Vendors provide us with a list of ten organizations that are willing to be interviewed, and we conduct one-hour teleconferences with the three of them whose organizational needs seem most likely to be similar to ours. The conference calls are most effective if both sides include clinical, managerial, and technical participants. In our experience, three calls are enough to provide consistent and reliable information. (See Appendix 13 for an example of a reference call protocol.)

• Information Security and Confidentiality—Our information security and conf- identiality office assesses the special-purpose software’s compliance with regulations and industry best practices and estimates any costs of meeting internal and external standards.

• Cost Estimates—IT estimates the costs of purchasing, implementing, and maintaining the software system, as well as the likely impact on already prioritized IT projects.

• Business Plan—The requesting practice or department completes a business plan for the project, including a standard return-on-investment (ROI) projection and capital request.

Case Study—GI Endoscopy Documentation and Billing

Geisinger’s Gastroenterology (GI) Department identified a report and image man- agement system (provided by ProVation®) based upon the following identified needs:

• Minimize physician documentation time with a combination of optimized docu- mentation and comprehensive, standardized clinical content.

• Bill accurately by way of:

• payer-compliant documentation and

• automated determination of billing codes.

• Acquire and store digital images efficiently.

• Add images to procedure reports to increase referring physician satisfaction.

• Capture and report standardized data for quality-improvement analysis, custom inquiries, and procedure performance logs for staff and trainees.

• Produce patient-education materials automatically.

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Needs Assessment—As the clinical and operations leaders and IT analyst performed the needs assessment, they studied nurse and technician staffing, room turnover requirements, current patient flow, and available space for holding and recovery. They concluded that decreasing the time required for physician documentation would not increase patient throughput unless the endoscopy rooms could be cleaned and pre- pared for the next patient faster. To address this, the practice manager increased staffing and changed workflows to remove bottlenecks.

Executive Confirmation—Senior clinical and operations leaders met to review the needs and confirm that they represented a high priority for the organization.

Gap Analysis—Review of our EHR implementation plan and consultation with our EHR vendor confirmed that our core EHR would not contain this set of features for at least three years. We also confirmed that our PACS and imaging-archiving system (IDX-Stentor®) did not plan to provide this set of features.

Market Assessment—We were unable to find serious competitors in this market or any definite information regarding the vendor’s financial viability. We were impressed with the results of the telephone conference calls, the performance of the software in real-world scenarios, the vendor’s commitment to research and development, and their business plan for a set of products representing the full range of image-related proce- dures. (The latter is significant to us, because it offers the possibility of an integrated suite of applications with a single set of interfaces into and out of our interface engine.

(See Figure 1.1, Chapter 11.)

Cost Estimates—Our IT analysts and the vendor collaborated on a set of technology- related costs for inclusion in the business plan.

Business Plan—Operational leaders projected the ROI conservatively, on the assumptions that: 1) there would be no interface for transmitting endoscopy results to the core EHR until after the project had succeeded, and 2) the system would be replaced by the core EHR in three years.

Results to-date include:

• Endoscopy room turnover time decreased from 15 minutes to five minutes.

• Procedure volume increased from 6,030 to 8,088 annually with no increase in rooms.

(We did add one physician, who accounted for approximately 950 of the 2,058 added cases.)

• Net financial benefit of $265,000 for the first year.

• Physician documentation time decreased from 12 to two minutes per procedure.

• The electronic interface of procedure results to the EHR was completed without complications.

Since the GI endoscopy project, we have applied the policy to five other requests. One resulted in fuller use of the core EHR; two resulted in purchase of special-purpose soft- ware; and two have needs analyses underway. Clinical and administrative leaders are coming to regard the process as the appropriate way to do business.

Conclusion

The following practices will result in a proactive, high-performance approach to special- purpose software:

a. Identify and prioritize high-impact areas for special-purpose software.

b. Work a process like that outlined above, holding leaders responsible for business-

plan results.

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c. If possible, conduct pilot projects before committing the organization to interface costs.

d. Identify vendors with the culture, current products, and business plan that make them potential long-term partners. (See Chapter 13.) Focusing on a few such vendors will enable you to simplify business relationships and minimize interface costs.

e. Persuade your core EHR vendor to cooperate with the special-purpose software vendor.

f. Pool your experiences of special-purpose software and vendors with other organi- zations who use your core EHR. Your collective experiences, particularly with issues such as interfaces, will be mutually instructive.

Reference

1. McDonald C. The barriers to electronic medical record systems and how to overcome them.

J Am Med Informatics 1997;4:213.

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