Report of the 8th Annual IAIMS Consortium Workshop

Session 1: What information services can we deliver through IAIMS that will improve practice competitiveness by optimizing care of the patient in the local setting?

1. Integrated patient record: What is the value of an integrated patient record in managing care across settings? What costs are associated and who should pay them? What new policies and processes are required to manage an integrated record within a single health delivery organization? across corporate boundaries?
2. Support needs: What kinds of support (e.g., decision support, just-in-time education, technical support) are needed by different types of providers in their practices?
3. Models of practice and communication: What new models of practice and communication are emerging to manage care efficiently and effectively across settings? What new elements in the information infrastructure are required by these models?

• Integrating Clinical Information from the Viewpoint of the Provider

Peter Tarczy-Hornoch, M.D., and Debra Ketchell, M.L.S.
University of Washington IAIMS Program

The goal of the University of Washington clinical informatics project is to extend the philosophy of comprehensive, integrated information access and management into the clinical arena. Our clinical projects are driven by an attempt to bring "just in time, just what you need" decision support information to the point of care. The source of the information can be the University of Washington patient database, knowledge resources, locally developed patient care guidelines, rules/reminders, or other useful decision support materials from anywhere in the world. Finally, once a decision is made, it is necessary to provide integrated communication tools to implement the plan. Ultimately the hope is that analysis of the the patient database itself will yield new knowledge which in turn will effect the guidelines, rules/ reminders, etc. effectively closing the loop. These projects have been collaborative efforts involving not only IAIMS personnel but significant personnel and resources from Medical Center Information Systems, campus-wide Computing & Communications, and Health Sciences Libraries and Information Center. The Clinical Information Advisory Committee serves as the steering committee for our efforts. For more information see: www.hslib.washington .edu/iaims/clinical
• The Vermont IAIMS

Julie McGowan, Ph.D., M.L.S., University of Vermont

Because Vermont is arguably the most rural state in the nation, with 67% of its population living in communities of less than 2,500, rapid access to information in support of health care delivery in rural areas is essential. In an effort to improve information access, the Vermont IAIMS has partnered with the Vermont Health Department to electronically collect and disseminate pertinent public health information to rural primary care providers. One or two examples of how this partnership has had an impact on health care delivery in Vermont will be discussed.
• Inreach-Outreach Strategy for Clinical Practice Computing

J. Robert Beck, M.D., Baylor College of Medicine, and Jenifer Blakeney, Baylor MedCare

Assimilating community practices into the integrated delivery system poses new challenges to the academic CIO. At Baylor we have pursued an "Inreach-Outreach" strategy, and have preliminary information on its success. The Inreach component addresses our medical center ambulatory practice, where we are steadily converting 620-plus independent physicians to a single group practice. Tactics include indemnifying departments, covering conversion costs to a central IDX platform, stimulating key physician buy-in, and developing a Computerized Patient Record Strategy. Outreach addresses the community practices, where we are offering academic support services as well as connectivity, logical extension of the clinical operations platform to Baylor-owned clinics, and CPR prototypes to follow. Problems with the strategy include the probable transience of some of these community relationships, making permanent connections illogical.
Approaches to the fluid integrated delivery system partnerships of the next several years may involve common carrier and intranet technologies as well as secure wholly-owned connections.

Discussion Group 1 Back to top

1. Communication for wide areas and local areas.
2. Multiple areas of access.
• Security controls
• Access controls
3. Competitive clinical practice environment.
• Managed care/capitated care
• Group practice
• Merging groups
• Self owned practice networks
4. Culture changes.
5. Expense of systems.
• Cost benefit analysis- Where do you reach the optimum deployment?
6. Explore how systems increased knowledge base can be expanded.
7. Becoming proactive instead of reactive.
8. Migration of current systems to Integrated Systems.

• Regional Systems:
1. Internal answers may be enhanced by the answer used to link outside technologies.
2. Does an integrated record require one system?
3. Funding of integration.
4. How do you find perceived value (set priorities)?
5. Clinical practice may not be the same as educational practice.
6. How and who manages the integrated record?

1. A Consortium generated reference architecture that would be independent of platforms. Components would include a public interface with independent interface engines.

Participant Issues:

1. Manpower -- especially to support remote areas. Need to become more packaged in our offerings.
2. Consistency of standards.
• Set minimum standards for those who want to link up.
3. Need to provide a multi-media support.
• Lean more toward services then technology.
4. Moving areas of clinical support.
• Home health.
• Hospice.
5. Identify what practice standards really mean.
6. Education in technology.

1. Need to provide agreement on the floor for architecture and technology standards.
2. We should be less technology driven and provide more information services.

Discussion Group 2 Back to top

Question 1: Integrated Patient Record

Question 2: Support Needs

The vast majority of physicians, as exemplified by those in Vermont, need basic resources including:

• Connectivity.
• MEDLINE.
• The 20% of the patient record which is most used.
• Lab results.
• EDI for determining eligibility and collecting claims quickly.
• Just in time continuing medical education.

Question 3: New Models of Practice and Communication

1. Provide leadership and education on these issues for academic administration, professional societies, and local medical societies.
2. Focus on providing the essential information (as discussed above) to the many physicians outside of academic medical centers.

Discussion Group 3 Back to top

1. The issues are complex -- technical, organizational, support.
2. Changes in technology and managed care environment occur faster than institutions can provide solutions. Some decisions need to be made NOW.
3. Many times no one solution will fit all (inpatient, outpatient, referring physician). There may be a number of solutions that must be integrated and accessible by authorized users. A very important issue is who owns the record and who can access it and for how long. Health care alliances are blurring the lines of who is an insider and who is an outsider. Again, no one solution may fit all.
4. Large financial investment with not much evidence for a return on investments. What studies have been done to show that health care providers access the data, use the data, and that this use produces better health care at reduced costs, or at least the same level of health care at reduced costs?
5. As more alliances are formed, there needs to be a shared authority over the integrated record and shared decision making about enhancements, changes, access policies, etc.

Question 2: Support Needs

1. Training and support are key to the success of any system, but institutions often do not invest enough in this area.
2. Institutional wide effort: IS, Library, other experts should be involved in training.
3. Need to define who gets trained: referring physicians, own faculty and staff, all Primary Care Providers in various alliances.
4. Given the number of people to be trained and the continuous need for retraining based on technology changes, training is a major investment for the institution.
5. Who pays for this training? The academic medical center, the hospital, the group practice? Would seem to work best if this training cost could be shared.

1. New models of practice will be based on patient outcomes; patient outcome data must be collected and analyzed.
2. May be difficult to get physicians to agree on the practice guidelines. What pediatricians think works best may differ from internists.
3. More and more practitioners need to get comfortable with e-mail. This is often a training issue.
4. Web based models will be used in the future.
5. There are and will continue to be a multiplicity of information networks, HMO's, and health care payers.

TAKE HOME MESSAGE: In a practicing IAIMS environment, patient outcome data will be collected and analyzed. Different practice guidelines can more easily be shared in an IAIMS environment. IAIMS can promote getting practitioners more comfortable with electronic communication. IAIMS can assist in facilitating communication among different information networks, various HMOs and their practitioners, and a number of different payers.