May 29, 2007

HIT’s Perfect Match — Best-of-Cluster Approach Marries What’s New with What Works
By Elizabeth S. Roop
For The Record
Vol. 19 No. 11 P. 20

Hospitals’ love affair with best-of-breed and single-vendor solutions appears to be losing steam. Instead, hearts are aflame for a model that seems to have the best of everything.

Health information technology (HIT) is the engine that drives today’s integrated healthcare delivery system. As a result, the expectations placed on applications and their ability to exchange electronic patient information in meaningful ways are higher than ever before.

No longer is it adequate for a hospital’s HIT system to simply store patient records or exchange information with the billing system. Now, it must also be able to share patient information along every step of the healthcare continuum. Plus, it must be able to do it in ways that help providers make better, faster care decisions without forcing them to weed through information that is not pertinent to the care being provided at that particular time.

As a result, a growing number of provider systems are foregoing the more traditional single-vendor and best-of-breed approaches in favor of a “best-of-cluster” strategy that allows them to keep what works, replace what doesn’t, and achieve a higher level of interoperability, clinical decision support, flexibility, and scalability.

“Best of breed was a great idea, when you think about it. Why should I compromise? I’ll get a one-of-a-kind system, and I’ll get the best combination [of solutions]. What people underestimated was the complexity, the enormous effort, the technologies needed, and the challenges to interoperability,” says Jay Srini, vice president of emerging technologies at the University of Pittsburgh Medical Center (UPMC). “With the best-of-cluster approach, we get the best of two options: the simplicity of a single-vendor solution, yet the flexibility and quality of the best-of-breed option.”

A Middle Ground
Perhaps the simplest description for the best-of-cluster approach is that it takes the best elements of the single-vendor strategy and blends them with the most effective elements of the best-of-breed concept.

Organizations that deploy a best-of-cluster model commit to a limited number of vendors who have a single, comprehensive, and common design and data approach for a few logical targeted areas within the facility, says Nivaldo Diaz, chief technology officer at Picis.

“The best-of-cluster model bridges the gap between a single vendor’s suboptimal support of focused clinical functions and the best of breed’s expensive and technically difficult integration issues,” he says. “Healthcare is complex to automate and requires balancing the priority of high-quality patient care with the responsibility of efficient management of resource.”

The cluster strategy provides the exact functionality and department workflow needed, which promotes clinician adoption and meets business objectives. It also ensures that users throughout the system have access to the right information, at the right time, and in the right place, which enables effective clinical decision-making.

Other advantages include the following:

• maximized system performance to achieve required functionality;

• improved management of work and data flow of common processes throughout the cluster;

• optimized data integration and interoperability;

• a limited number of vendors, spreading the risk and easing the management process; and

• reduced total cost of ownership due to fewer vendors to manage and fewer interfaces, without sacrificing functionality or capabilities.

“The biggest challenge is to select the four to six vendors who are best in their class and able to provide interoperability,” says Diaz. “In addition, providing focused, efficient workflow with tight functionality between areas while balancing the special requirements and flexibility needed for different types of users is challenging. This ties together functionality, data sharing, and common content.”

Best of cluster also eliminates the need to compromise functionality for a high degree of integration, which is typically the outcome with a single-vendor solution, adds Ilan Freedman, vice president of marketing for dbMotion. At the same time, it reduces the number of vendors that must be managed under the best-of-breed approach and the number of interfaces that must be created to allow the systems to converse. That, he says, is what makes it the best of both worlds.

“You’re able to have a manageable landscape in terms of integration and use the better breed of interoperability tools that is out there today, from an interoperability standpoint, to reach a degree of integration between these [disparate] products that is just as high, if not higher, than the single-vendor approach would offer,” says Freedman.

For example, UPMC was utilizing Epic for its ambulatory care registration system but also needed an acute care system, which Epic did not offer at the time. The facility looked to Cerner, which could have managed both sides, but decided to go with the individual strengths of each application. Thus, UPMC now utilizes Cerner for the majority of its acute care centers and Epic for the majority of its ambulatory centers.

For its enterprise master patient index, which is one of the largest in the country, UPMC opted for Eclipsys over Cerner due to its scalability and size. In other areas, such as the specialty care centers, laboratory, etc, the existing systems were standardized with enterprise solutions or replaced with one that was best suited to that area’s specific needs.

“You look at this and say, ‘This looks like a single-vendor solution across the various classes,’ but it is actually a cluster,” says Srini. “A single-vendor approach transformed itself into a best-of-cluster. It wasn’t as though we had several vendors in different areas, but rather we had clusters of areas … We may have more than one vendor per class, but it’s not like we have every possible system available.”

Advancing the Interoperability Case
In addition to streamlining vendor management and maximizing functionality, a best-of-cluster approach also overcomes many interoperability challenges created by the single-vendor and best-of-breed approaches.

“A cluster approach reduces interoperability challenges because the vendor’s strategic focus is broader than a niche area. Those areas are tightly integrated between themselves in a best-of-cluster solution without the need for additional interfaces and therefore more highly interoperable,” says Diaz. “A cluster approach far outweighs narrowly defined, inflexible single-vendor systems or best of breed that is functionally challenged for a specific high-acuity environment.”

A heightened level of interoperability also allows the provider organization to focus on strategic outcomes as opposed to individual vendor offerings. That, in turn, leads to an HIT solution that takes advantage of existing processes that work well, combining them with new technology and processes designed specifically to achieve the optimal outcome as identified by the facility and its end users.

“To me, conceptually, you take the things that are working best for you and leave those processes in place. Then, using interoperability tools, you work on solutions rather than getting hung up on the individual pieces,” says Joel Diamond, MD, chief medical officer in North America for dbMotion. “The emphasis is on what you want to attain at the end of the day. Everyone says they want interoperability, but when you ask them why, they say, ‘Let me stop and think about that.’ The ‘why’ should be first and foremost in everyone’s mind, and then we can see what pieces are needed to accomplish that goal. That’s a better exercise than looking at which vendor does what.”

For UPMC, the cluster approach laid the groundwork for a massive interoperability initiative that will ultimately allow data to be shared between the disparate systems scattered throughout the $6 billion organization’s 19 hospitals, 400 ambulatory care centers, and a health plan that covers nearly 800,000 members, as well as with other provider organizations throughout western Pennsylvania.

The $84 million initiative is designed to ensure interoperability among clusters throughout the system and provide a high level of clinical decision support that goes beyond sharing information to incorporate evidence-based support at the point of care, regardless of where a patient is along the care continuum.

“At the very base level, it’s integration, harmonization, semantics, and interoperability,” says Srini. “The next layer is advanced decision support. The third layer is what I call business intelligence for clinical trial data mining,” which will streamline the process of identifying candidates for trials underway at UPMC, among other things.

“For our organization, for our size, to be able to get the simultaneous advantages of patient safety, quality of care, and economies of scale, the most prudent way was to go with the best-of-cluster approach,” she adds.

For Diamond, the most exciting aspect of the UPMC initiative—and where dbMotion comes into play—is the opportunity to create decision support interfaces that not only share patient information across venues but also present that information in a way that is familiar, comfortable, and appropriate for the end user.

The idea, he says, is to build interfaces capable of screening out the noise in the system so the presented information is appropriate for the care setting.

“It’s great to do decision support. It’s great to have reminders. It’s great to have a computer check for interactions. But to be able to do that over a broad range of venues because you have shareable information is very important,” says Diamond. “It gets us out of the silo of thinking of our patients as going from one bricks-and-mortar institution to another. [Right now], that’s the way we envision care.”

Flexibility, Scalability, Affordability
The UPMC initiative is a large-scale example, but the best-of-cluster approach can also benefit smaller systems, individual facilities, and even physician offices. Because it does not require the complete replacement of systems and processes—and because it limits the number of interfaces required to facilitate information exchange while still allowing for expansion—it can be a viable and affordable alternative.

“They [healthcare organizations] have made significant investments in time, resources, and money into certain processes and technology. To build a better mousetrap and undo those processes is painful and costly,” says Diamond. “The best-of-cluster approach means they don’t have to do that. They can keep those processes that work well for them and add new features. Especially given an SOA [service-oriented architecture] backbone, it really makes it much more affordable. More importantly, we don’t know what new applications we’re going to need next year or five years from now. If we have this kind of structure as the backbone, we know we can fit all those pieces in as time goes on.”

A best-of-cluster strategy is also well-suited for networks and systems that are in expansion mode, whether organically and requiring the addition of new systems or through expansion and requiring integration of the systems from the acquired facilities.

For UPMC, the best-of-cluster approach has allowed it to develop a franchise model for integrating new systems and facilities, easing the pain that often accompanies mergers, acquisitions, and expansions. It also lets the organizations be more responsive to the unique needs of end users while still achieving economies of scale in contracting and strategic partnership with its application vendors.

“Trying to use best of breed for each hospital, and trying to link them up, would have been too expensive. There would not have been enough of a learning curve advantage from one [integration] to the next, and it also would not have given us the level of sophisticated interoperability we were seeking,” says Srini, adding that best of cluster “definitely provides a roadway to enable the acquisition of new institutions and the expansion into the global arena more easily, less expensively, and more effectively.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.