Sept 26, 2006

"RHIOs Tackle Systems Integration"

Integrating data in various clinical and administrative systems with a Web portal can be challenging for any health care organization. Knowing that, imagine the integration tasks for an entity that is trying to link numerous provider and payer facilities to an online portal.

Regional health information organizations are trying to do just that, and the connectivity issues are numerous and daunting. RHIOs conceivably can use the same technologies, such as HL7, SOA and messaging standards, hospitals and delivery systems use to integrate back-end systems with Web portals. But few, if any, organizations have attempted integration initiatives on the scale RHIOs will, and no best practices have been written as to exactly how it should, or can, be done.

"To ease the implementation of RHIOs, industry standards should be developed for how all their systems should be integrated," says Eric Bartholet, partner at Computer Sciences Corp., an El Segundo, Calif.-based consulting firm. "There's a common model emerging, however, for RHIOs to use a hub that can point to a thin level of data in each system so each hospital doesn't have to release all its data to a common database."

HealthBridge, a third-party, online hub for hospitals and providers in the Cincinnati area, is enabling only test results data to be integrated with its physician Web portal.

The organization uses messaging technology from Tampa, Fla.-based Axolotl Corp. to connect lab and other results reporting systems at participating hospitals. The messaging system-which uses messaging standards from Ann Arbor, Mich.-based Health Level Seven- transfers data from each application to a main server located in a centralized data center.

The server then converts the data into a standardized format and sends it to a Web server so physicians can view it via a clinical messaging page within the portal.

Before unveiling the integrated results messaging on the portal, HealthBridge had representatives from each of its hospitals develop a standard format for the results to be displayed. The collaboration helped the organization maintain more control over the portal than it would have with multiple reporting methods, says Robert Steffel, executive director.

"Offering results in a standardized format has tangible benefits, but it also lets people get together to create an understanding of who's doing what in their organization," he says. "You need trust for a health information exchange to work."

HealthBridge, however, decided not to integrate information from the various picture archiving and communication systems, electronic medical records applications and other software that participating hospitals use into a single database for the Web portal. Instead, physicians can log directly into those applications through the portal.

"We think of the portal as a way to concentrate user access to all of our systems," Steffel says. "If physicians want to look at data that's not pushed to them directly via the clinical messaging, they can use the portal to access the native application."

Building A Single-Source Portal

But regardless of whether interfaces are created via SOA, HL7 or other technologies, such complex development work requires an advanced skill set for programmers, and such advanced skills aren't widely found in health care I.T. shops, Bartholet says.

Organizations that don't have the I.T. skill sets needed to create Web portal interfaces to their back-end systems often end up outsourcing such work to portal software vendors. Many of these vendors have a ready supply of interfaces-or have staff with the skill sets needed to build them-for common health care applications using HL7 and SOA technologies.

"Creating interfaces or integrating systems takes lot of development, so it usually becomes a buy versus build type of decision at many organizations," says Pete Rivera, senior health care consultant at Hayes Management Consulting, Newton Center, Mass.

Creating Web portal connections to its information systems is not something that Delnor-Community Hospital's I.T. staff is trained to do, says Dee Ramierez, a system analyst at the Geneva, Ill.-based provider organization. So the hospital reached out to a few different companies to integrate back-end systems and a series of portals that were expected to go live between August and October.

"We are not a development shop," Ramierez says. "We're leaving that to our vendors."

When all the portals are live, they will offer, among other services:

* Online performance reviews on the employee portal that automatically initiate pay raises.

* Web-based hiring tools on the consumer portal.

* Appointment scheduling on the patient portal.

Delnor-Community hired Iatric Systems Inc., Boxford, Mass., to create customized, outbound interfaces from its hospital information system, from Westwood, Mass.-based Medical Information Technology Inc. The interfaces, which Iatric created using HL7 standards, offer a way to search the clinical information system for specific sets of data.

Delnor-Community also hired MedSeek to provide technology that could perform queries in the system and transfer specific data to multiple portals. The vendor's technology, ePlatform, comprises several smaller programs-or tasks-designed to retrieve specific types of commonly used data, such as scheduling information. It then transfers the data to a Web portal tool, where it can be used to populate a portal. The technology's tasks were created via SOA.

MedSeek uses the data its ePlatform has queried to populate employee, patient, consumer, executive board and physician portals for Delnor-Community. The vendor also is using its SOA-based technology to pull data from various medical content applications the hospital uses and transfer it to the portals.

Additionally, Delnor-Community is working with LVM Systems Inc., Mesa, Ariz., to create applications for physician locators and class registration, which will be transferred as tools on its consumer portal.

Follow-up necessary

While the hospital farmed out the systems integration work for its Web portals, Ramierez spent numerous hours coordinating weekly calls between the hospital and its integration vendors to determine a functional design specification of what and how data and processes would be affected for each interface with each portal.

"It's really a collaboration of efforts from everyone," Ramierez says. "It's key to have all parties talk to each other."

As a small, 118-bed hospital with limited I.T. resources, Delnor-Community had to outsource the integration work it needed to connect a single health care information system and various content applications to its Web portals. While some larger provider organizations might have the skill sets needed to integrate a comparatively small number of applications, they often need a helping hand to create the hundreds of interfaces required to connect their systems.

St. Louis-based Ascension Health, for example, is a multistate organization operating 64 acute care hospitals and 20 other health care facilities, each with its own I.T. department. Even though it has about 750 I.T. staff members, the organization still needed to outsource some of the systems integration work required to offer Web portals for patients, physicians, nurses and other groups, says Mark Greenly, chair of its technology council and director of health care information systems.

"We didn't have a consolidated view of our enterprise because we grew up as hospitals with independent infrastructures," Greenly says.

To get a better handle on its resources, Ascension Health hired Computer Sciences Corp. to a multiyear contract to run its I.T. operations and help integrate its 2,000 clinical information systems.

The consulting firm helped Ascension Health create an enterprise, Web-based data warehouse that could receive data from each of the provider organization's clinical systems. This way, only one interface had to be created for each system, Greenly explains.

"There would have been too many interfaces and too many points for failure any other way," he says.

Though it limited the number of potential interfaces it needed, Ascension Health still faced the task of integrating various information systems to the database. It was able to use HL7 standards to create interfaces between some clinical applications and the Web database.

But it had to use other tools to transfer data from its ancillary laboratory and admission-discharge-transfer systems. Ascension Health used the exchange, transfer, load tool found in many database applications to transfer information from these systems to the Web database. It then used Extensible Markup Language, or XML, a Web services tool, to tag the data so it could be used with other Web services to transfer it to a portal.

The delivery system has enabled physicians to use its Web database, though not via conventional portal methods, Greenly says. Physicians can request I.T. staff to mine the database to analyze clinical trends among the various hospitals in the delivery system. Doctors view the data via a Web browser, much like they would in a portal environment. Real-time portal functions, including applications for nurses, patients and other groups are planned for next year, he adds.

Up for a challenge

As Ascension Health found, not all information systems can be integrated to a Web portal using the same technology.

"Developing interfaces between an application and a Web portal depends on the vendor and how complex its system is," says Rivera, at Hayes Management Consulting.

For example, HL7 standards don't work for certain information systems, such as financial applications, or diagnostic imaging systems, which use Digital Imaging and Communications in Medicine, or DICOM, to communicate, says Bartholet, at Computer Sciences Corp.

So health care organizations - or their Web portal vendors - often have to use more complex Web services or other tools to create interfaces between these types of systems and Web portals.

Saint Mary's Hospital had to use Web services technology when it decided to integrate its picture archiving and communications system to its portal. The Waterbury, Conn.-based hospital's Web portal, from McKesson Corp., San Francisco, was designed as a conduit to view data from the vendor's software the hospital uses, which includes applications for pharmacy, documentation and clinical information systems.

Some health care organizations only integrate information systems from a single vendor with their Web portals (see sidebar, page 46). Saint Mary's I.T. staff, however, expanded its Web portal by using HL7 messaging standards to connect other ancillary applications to it, including its lab system, from Misys Healthcare Systems, Raleigh, N.C., and radiology information system, from GE Healthcare, Waukesha, Wis.

The portal is populated from a McKesson Web database server, which can store only text, not images. So Saint Mary's had to use a different Web services technology-SOAP-to link its PACS, from DR Systems Inc., San Diego, to the portal.

SOAP and data

SOAP, or Simple Object Access Protocol, is an XML-based messaging technology that sends information between Web-based applications.

"SOAP is the list of rules you write in XML to pass messages of data between systems," says Lawrence Stuntz, a partner at Computer Sciences Corp. "Image data can be contained in the message. It's a good integration technology because it runs over the Internet."

To create the interface, DR Systems built an HL7 outward interface from its Web-based PACS server that Saint Mary's uses. Now each time a PACS image is created or updated, the server creates an HL7 message containing an ID of the image and a URL that describe where it has stored that image. For its part of the interface, Saint Mary's used the Java programming language to create applications on its Web server that receive and analyze the message. It instructed the applications to use SOAP messaging to transfer the image information to a Web database for storage.

When a physician wants to access the image via Saint Mary's Web portal, the portal application also uses SOAP messaging to retrieve the image URL information from the database. It then opens a Web application to display the image.

"The Web services/SOAP technology sits in front of our Web server so the portal can talk to the PACS," says Steve Burrows, integration analyst. "It keeps open connections between the databases."

Web services technologies also are commonly used by payers to integrate data from their proprietary back-end systems to Web portals.

Highmark Inc., a Pittsburgh-based Blues plan, is using a variety of technologies, including Web services, to transfer transactions data from its information systems to a physician portal. It's doing so via the NaviNet Web provider/payer communications platform from Cambridge, Mass.-based NaviMedix Inc.

The main transfer technology used between Highmark and the NaviNet system is Websphere MQ, from IBM Corp. Websphere MQ can be used as an enterprise service bus, or message broker, to connect messages requesting data created via Web services and information systems. It can be used to connect applications running on different operating systems or as a conduit to transport data using Web services.

Highmark's portal, which NaviMedix hosts, uses Websphere MQ to transfer data, such as eligibility and benefits, claims status and referral information back and forth between the Blues plan's proprietary information systems.

Highmark also enables physicians to use its portal to initiate such transactions for a patient who's a member of another Blues plan.

When a physician requests information from Highmark's portal for a patient who's a member of another Blues plan, the portal sends the request to Highmark's back-end systems. The request then is transmitted to BlueExchange, a Web-based system designed to process and validate eligibility, claim status and referrals for members of all Blues plans.

"As we got more and more members, we wanted to automate more functions for them," says Chris Scockhouses, application specialist for Highmark's provider portal care management system. "So we built bridges to transfer the data required for them. We're ahead of the curve with what we've built."

RHIOs Tackle Systems Integration

Integrating data in various clinical and administrative systems with a Web portal can be challenging for any health care organization. Knowing that, imagine the integration tasks for an entity that is trying to link numerous provider and payer facilities to an online portal.

Regional health information organizations are trying to do just that, and the connectivity issues are numerous and daunting. RHIOs conceivably can use the same technologies, such as HL7, SOA and messaging standards, hospitals and delivery systems use to integrate back-end systems with Web portals. But few, if any, organizations have attempted integration initiatives on the scale RHIOs will, and no best practices have been written as to exactly how it should, or can, be done.

"To ease the implementation of RHIOs, industry standards should be developed for how all their systems should be integrated," says Eric Bartholet, partner at Computer Sciences Corp., an El Segundo, Calif.-based consulting firm. "There's a common model emerging, however, for RHIOs to use a hub that can point to a thin level of data in each system so each hospital doesn't have to release all its data to a common database."

HealthBridge, a third-party, online hub for hospitals and providers in the Cincinnati area, is enabling only test results data to be integrated with its physician Web portal.

The organization uses messaging technology from Tampa, Fla.-based Axolotl Corp. to connect lab and other results reporting systems at participating hospitals. The messaging system-which uses messaging standards from Ann Arbor, Mich.-based Health Level Seven- transfers data from each application to a main server located in a centralized data center.

The server then converts the data into a standardized format and sends it to a Web server so physicians can view it via a clinical messaging page within the portal.

Before unveiling the integrated results messaging on the portal, HealthBridge had representatives from each of its hospitals develop a standard format for the results to be displayed. The collaboration helped the organization maintain more control over the portal than it would have with multiple reporting methods, says Robert Steffel, executive director.

"Offering results in a standardized format has tangible benefits, but it also lets people get together to create an understanding of who's doing what in their organization," he says. "You need trust for a health information exchange to work."

HealthBridge, however, decided not to integrate information from the various picture archiving and communication systems, electronic medical records applications and other software that participating hospitals use into a single database for the Web portal. Instead, physicians can log directly into those applications through the portal.

"We think of the portal as a way to concentrate user access to all of our systems," Steffel says. "If physicians want to look at data that's not pushed to them directly via the clinical messaging, they can use the portal to access the native application."

Northwest Florida Heart Group wanted to get a leg up on its competition by offering patients the ability to complete various transactions via the Internet. But the seven-physician cardiology practice didn't have the resources to migrate data from its practice management and electronic medical records systems - from Raleigh, N.C.-based Misys Healthcare Systems - to a Web portal.

"We wanted to focus on improving data flow to our patients rather than on building interfaces," says Bill Suffich, practice administrator. "We don't have the I.T. resources that a larger clinic might have, so we were forced to use a third party for our portal."

Instead of outsourcing the integration to a portal vendor or a consulting firm, Northwest Florida Heart group turned to its single-source clinical systems vendor. Last April it purchased the PatientLink Web portal, which integrates data from those applications to an online site. The single-source system, which Misys offers via a partnership with MedFusion Inc., a Research Triangle Park, N.C.-based vendor of physician Web sites, was built using Web services to move data between the vendor's applications and a portal.

The technology offers data integration of the Misys applications for common health care transactions that can be conducted via a portal, such as appointment scheduling and bill payment. Northwest Florida Heart Group has used the vendor's technology to develop separate portals for its physicians and administrators.

Because the group practice outsourced the systems integration work required for its Web portal, it has been able to focus on redesigning the processes for performing the transaction offered on it, as well as marketing them to patients, says Bill Suffich, practice administrator.

Though they often have larger I.T. departments than group practices, some hospitals also turn to their clinical software vendors for the integration work required for Web portals. For example, Los Angeles-based Cedars-Sinai Health System is having the vendor of its call center scheduling and registration databases-Orlando, Fla.-based Connextions-integrate the applications with a Web portal.

The delivery system ultimately wants to have patients schedule appointments and register for classes via the portal. It also wants the portal, which will display data only from systems from Connextions, to serve as a customer relationship management tool that enables marketing staff to analyze call center patient data, says Michael O'Malley, director of marketing.

"We chose Connextions because of their skill sets in building applications and integrating them," he says. "So our I.T. department never had to build our call center applications or Web portal."

The vendor is integrating its systems using Web services to create transactions that transfer specific data sets from the call center applications to a portal database, explains Tom Young, M.D., senior vice president and corporate medical director at Connextions.