Title: Partners Health Care Systems (PHS): Transforming Health Care Services Delivery through Information Management

According to government sources, U.S. expenditures on health care in 2009 reached nearly $2.4 trillion dollars ($2.7 trillion by the end of 2010).[1] Despite this vaunting national level of expenditure on medical treatment, death rates due to preventable errors in the delivery of health services rose to approximately 98,000 deaths in 2009.[2] To address the dual challenges of cost control and quality improvement, some have argued that what is needed is an integrated electronic medical record (EMR) system and associated information technology-enabled processes.[3] While the information systems currently available area may meet the needs of the industry, the question remains as to what is required within and by the health care services organization to achieve a satisfactory response to these dual challenges.

At the present time, Partners Healthcare System (PHS) maintains a centralized digital records library on over 5 million patients, augmented in real-time by data, textual comments, and artifacts (i.e. x-rays, MRIs, EKGs, etc.) as these patients visit doctor offices, receive hospital-based or home care services, and obtained prescription medications and other therapies. Procedures are in place to ensure the data quality and integrity of these patient files. Going forward, any health care professional across the network can access a patients complete record, ensuring accurate, timely, and comprehensive information sharing about that patients medical history, allergies, current treatments, and so forth. In and of itself, this investment in this electronic medical records system (EMR) - called the Longitudinal Medical Record or LMR within Partners - is expected to reduce delays in service delivery, mistakes in treating the patient, and overall health care costs. When coupled with a Computerized Physician Order Entry system (CPOE) to inform the selection of drugs and appropriate treatment, PHS health care professionals are now positioned to target more specific therapies for their patients, to identify the most effective, low-cost options among potential treatment strategies, and to draw on a vast body of experience-based knowledge across the network to inform patient care.

Partners HealthCare was founded in 1994 by the partnering of Brigham and Women's Hospital and Massachusetts General Hospital and became an integrated health care delivery system that offered patients a continuum of coordinated high-quality care. As of 2009, the system included 6,300 primary care and specialty physicians, eleven hospitals including its two founding academic medical centers, specialty facilities, community health centers and other health care-related entities, and an ongoing affiliation with the Harvard Medical School. In 2008, Partners HealthCare serviced approximately 2.9 million outpatient visits, processed 20 million prescription drug orders, and admitted patients 149,000 to one of its hospitals. Its facilities at that time included 3,500 licensed hospital beds, serviced by 40,000 (FTE) employees across its network of affiliates, including 6,000 independent but affiliated physicians. For FY2008, Partners generated over $7 billion dollars in revenue and conducted approximately $1 billion dollars worth of biomedical research.

PHS maintains a substantial information management arm. The 2009 information Systems (IS) team comprised 1,500 employees operating out of nineteen locations in the greater Boston metropolitan area. With an operating budget of $196 million dollars in FY2009 and a capital FY2009 budget of $68 million dollars, IS supported 80,000 end users and 82,000 networked computer devices running in 140 Partners locations. In an average month in 2009 the IS organization answered 18,000 help desk calls, and over the course of that same year managed 250 major information technology (IT) projects for the enterprise. To realize its information management objectives, PHS has invested heavily in information technology over the years and hired some of the best information management professionals in the industry.

PHS recognized early on that to be successful in the deployment of enterprise systems, such as LMR and CPOE, three information management capabilities were required:

the means to collect and consolidate into an integrated digital record all the information about a given patient over time, including: medical data, such as age, weight, height, vital signs, et al.; textual information, namely the transcribed comments of those health care professionals with whom the patient interacts; and objects, such as x-rays, MRI scans, and the like.

decision support processes that support the medical practitioner in making the best recommendations for drugs and other therapies based upon their likely benefits (i.e. positive outcomes) to the patient in question at the lowest possible cost.

knowledge management processes that derive best practices from the observable outcomes of recommended medical therapies and employ these lessons learned to inform the ongoing delivery of services and the reform of existing therapies.

Going forward the operational requirements faced by PHS member institutions in this regard are two-fold. One the one hand, each institution is obliged to establish processes to capture all on-going health care information digitally and to convert past paper-based medical records to a shareable digital format. On the other hand, due to the increasing interaction among members of the PHS services network, it is also essential that patient information residing anywhere within the network be made available to all PHS service providers.

To address these requirements, PHS business units underwent significant process changes and the enterprise as a whole adopted an information management and technology architecture and platform that have proven flexible enough to deal with the differences posed by the various information systems and digital record formats extant within PHS. Key among these innovations was the adoption and widespread use of a Computerized Physician Order Entry system (CPOE) that captures patient prescriptions and other doctor-assigned medical therapies.

The successful implementation of these information systems depended largely on their adoption and use by health care practitioners across the PHS network. To that end, the rollout plan involved service delivery process reengineering as well as the extensive initial training and ongoing support of end users. In addition, the IS unit provided a robust, integrated platform for the collection, processing and dissemination of information across the PHS network, and they also worked to ensure the quality and integrity of the data going into these systems and processes. The new data management platform embraced a so-called service oriented architecture. The attributes of this platform included:

A single, enterprise repository and list for each of the key data types (allergies, medications, and problems )

All software capable of reading from and writing to these lists

Standard data definitions applied to support the back-end aggregation of key clinical data for decision support, and quality reporting

Standards for clinical knowledge across the enterprise

Knowledge Management process and procedure for achieving clinical consensus on the rules governing system decision making processes

Variation in the workflow of applications that are consistent with PHS medical and service delivery practices

Workflow-based applications should demand some key work processes and data displays that lead to demonstrated superior results[4]

The implementation of the LMR within PHS also called for a high level of data quality. The mechanisms for data collection, validation, cleansing and warehousing, as part of enterprise-wide process improvement, were all made more rigorous. In addition, the IS organization faced the need to review the rules engine that enabled its CPOE platform. Over the years, millions of rules, concerning such subjects as prescribed dosages, drug interactions, the recommended sequencing of therapies, and the like, had found their way into the CPOE knowledge base. The provenance for many of these rules remained obscure and the relevance/accuracy of others were in doubt. Given the vital importance of a current and accurate set of rules with CPOE decision-support system, IS took on the re-documentation and clean-up of the systems knowledge base, as well as the establishment of a more rigorous process for the ongoing maintenance of rules engine. Like the rollout of LMR, the improvement of the PHS knowledge management process progressed in phases. The clean-up phase gave way to a more formal assignment of content stewardship by subject matter experts. This led ultimately to the regular authoring and updating of best practices that better informed health care delivery across the PHS network.[5]

Glossary:

Computerized Physician Order Entry (CPOE) System an information system that is employed by physicians and other healthcare practitioners to directly enter orders for medications, diagnostic tests, and ancillary services.Current versions of these systems typically include decision support tools and an automated knowledge base to inform decision making where both the vendor of the system and the healthcare professionals who use the system may enter information and rules to influence the systems recommendations.

Database A structure and efficient mechanism for the storage, description and management of discrete data elements and bodies of agency information.

Decision Support System (DSS) An IT-enable system that facilitates the integration of critical agency information so that management may employ that information to inform planning and decision making.

Electronic Medical Record (EMR) system an information system that facilitates the collection and consolidation into an integrated digital record all the information about a given patient over time, including: medical data, such as age, weight, height, vital signs, et al.; textual information, namely the transcribed comments of those health care professionals with whom the patient interacts; and objects, such as x-rays, MRI scans, and the like.

Infrastructure The backbone of IT delivery, the networks, communication services, operating systems, servers, desktops, and related platforms, products and services that provide IT capabilities to the end user.

Knowledge Management (KM) A range of practices used in an organization to identify, create, represent, distribute and enable the adoption of insights, best practices, and experiences. Such insights and experiences comprise knowledge, either embodied in individuals or embedded in organizational processes or practice.KM efforts typically focus on organizational objectives such as improved performance, competitive advantage, innovation, and the sharing of lessons learned

LMR the Longitudinal Medical Record; Partners HealthCares internally developed electronic medical records system.

Medical Informatics - The intersection of information science, computer science, and health care, medical informatics explores, designs and delivers the information management services required to optimize the acquisition, storage, retrieval, and use of information in health care and bio/medical organizations.

Service Oriented Architecture (SOA) An approach to systems design and deployment that aims to loosely couple applications so as to facilitate access to particular bodies of data or system capabilities without recourse to more formal systems integration.In the context of the PHS information management platform, a service oriented architecture more readily accommodate information sharing among organizational and business entities operating different information systems but needing to share a common body of content (e.g. data, text documents, and digital objects, such as photographs and x-rays.

1. List any course concepts that can be applied. NEED FULL EXAMPLES, RELATION TO CASE, AND ALSO ANY POSSIBLE ADVANTAGES OR DISADVANTAGES OF EACH
   1. DSS
   2. LMR
   3. EMR
   4. DATABASE
   5. INFASTRUCTURE