advantages of integrated (homogenous) systems john gilbertson md associate chief of pathology...
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Advantages of Integrated (Homogenous)Systems
John Gilbertson MDAssociate Chief of Pathology
Director of Pathology InformaticsMassachusetts General HospitalAssociate Professor of Pathology
Harvard Medical School
HARVARDMEDICAL SCHOOL
Pathology Informatics 2010John Gilbertson: Monday September 20
Integrated (Homogeneous) System:
• An information system, that supports multiple, horizontal activities and is sold and maintained by a single company
• The degree and method of the integration can vary
• There are other was to integrate: third party, open standards
Pathology Informatics 2010John Gilbertson: Monday September 20
Thesis
• When the workflows and data structures of two laboratory activities become similar there are compelling reasons to integrate under a single system
• AP and CP are converging in a number of ways, and it is time to think about integration of the LIS systems. Both the convergence and the integration will take time
• We have moved our AP and CP platforms to a single vendor to facilitate this convergence
• While not the only approach, homogeneous integration allows departments to focus developmental resources in other areas
Pathology Informatics 2010John Gilbertson: Monday September 20
The MGH – Sunquest Co-Development
• MGH and Sunquest have established a long term collaboration agreement for the co-development of aspects of future versions of the Sunquest Copath AP LIS
• Under the terms of the agreement, both MGH and Sunquest will provide resources to the development of LIS modules that will be commercialized (generally available) and maintained by Sunquest. MGH will receive a revenue stream back from Sunquest based on the resources provided and the commercial success of the modules
Pathology Informatics 2010John Gilbertson: Monday September 20
The case for (homogeneous) integration
Pathology Informatics 2010John Gilbertson: Monday September 20
Sometimes activities are so different, that an “integrated” system is not needed or is too complex to be effective…
…. or even to be understood
Pathology Informatics 2010John Gilbertson: Monday September 20
As long as best of breed is providing significantlybetter performance there is no case for integration
There is real value in specialization….… “Best of Breed”
CP LISAP LIS
Pathology Informatics 2010John Gilbertson: Monday September 20
If the differential performance begins to decrease,combining the systems begins to have real value
CP LIS
Microbiology
Chemistry
Heme
Pathology Informatics 2010John Gilbertson: Monday September 20
Operations
x 3
The value of (homogeneous) integration
Disaster Recovery
Hardware
Upgrades
Patches, Security
Management Reports
Dictionary Maintenance
OS, DB, Development Kits
Licenses
MeetingsMeetings
AP TMCP
None of this adds value
Pathology Informatics 2010John Gilbertson: Monday September 20
Interfaces
Interface maintenance
“Handoffs”
x 3
Data Models / Relations
Timings
HIS
Imaging
AP TMCP
The case for (homogeneous) integration
Pathology Informatics 2010John Gilbertson: Monday September 20
Subsystems
Pyramids of sub-systems
x 3
Image ImageImage
AP TMCP
HIS
The case for (homogeneous) integration
Pathology Informatics 2010John Gilbertson: Monday September 20
Subsystems
Device Interfaces
x 3
Image ImageImage
AP TMCP
HIS
The case for (homogeneous) integration
Pathology Informatics 2010John Gilbertson: Monday September 20
Personnel
Personnel
Call
Admins
x 3
PACS PACSPACS
AP TMCP
HIS
The case for (homogeneous) integration
Training
Backup
Succession
Pathology Informatics 2010John Gilbertson: Monday September 20
Societal
Feudalism
x 3
The case for (homogeneous) integration
Pathology Informatics 2010John Gilbertson: Monday September 20
The cost of castles
Strategic:Enterprise LeverageProject LeverageOpportunity Cost of Projects
Medical:Data and Operational FragmentationIntellectual Schism Limits the pathologist as an integrator and interpreter of laboratory dataThe opportunity cost of consultation great-castles.com/index.pl?official.html
Pathology Informatics 2010John Gilbertson: Monday September 20
AP LIS CP LIS AP LIS
When the performance of a homogenous integration approaches theperformance of best of breed it is time to consider homogenous integration
None of this matters if the best of breedsystem is providing better performance
We think we are getting very close
Pathology Informatics 2010John Gilbertson: Monday September 20
• Will it the integration be homogenous or will you do it yourself?
• Do you have the resources to do it - – Time– People– Money– Test– Train
If integration is possible and worth the cost…
• Who is in charge?
• Will you be able to maintain it?
CP LIS AP LISAP LIS
Pathology Informatics 2010John Gilbertson: Monday September 20
• Do you have nothing better to do?
Pathology Informatics 2010John Gilbertson: Monday September 20
Clinical Laboratory for Research and the Bio-repository(CLR)
Pathology Informatics 2010John Gilbertson: Monday September 20
Clinical Laboratory for Research and the Bio-repository
• Need for a laboratory to do clinical pathology work and tissue banking for clinical trials and translation research projects
• Work had been done in the clinical lab but this proved inefficient and expensive
• Initial software was home grown, was not scaling and developers had left the institution
???LIS
Clinical Lab CLR
Pathology Informatics 2010John Gilbertson: Monday September 20
Clinical Laboratory for Research and the Bio-repository
• CLR did clinical testing for clinical trials and tissue banking
• Additional (special) functions required
• Data exchange with the main clinical lab for 24/7 and full test menu
• Accept discarded clinical specimens (for banking) in future
Tissue (blood) bank
Extra Data Collection
Consent Status Aware
Research Billing
Batch Accessioning
Special research reports
Requisitions consistent with protocols
Selected results to EMR
Integration with “EMSI” and “RFDR”
Pathology Informatics 2010John Gilbertson: Monday September 20
We decided to use an second instance of our CP LIS
Pathology Informatics 2010John Gilbertson: Monday September 20
LIS
MULHOS (CP LIS)
BillingADTResults
Batch
EMSI
R-EMR
HL7
SpecimenInventory
Straw AliquoterClinical Lab
Tissue bank front end
Tissue bank Inventory
Consent Status Aware
Research Billing
Special research reports
Batch Accessioning
Requisitions consistent with protocols
Selected tests to EMRIntegration with “EMSI” and “RFDR”
Data exchange with the main clinical lab
CLRLIS
Pathology Informatics 2010John Gilbertson: Monday September 20
LIS
MULHOS (CP LIS)
LIS
BillingADTResults
Batch
EMSI
RPDR
HL7
SpecimenInventory
Straw Aliquoter
Training
Interfaces
Personnel
Maintenance
D.R.
Hardware
Dictionaries
No castles
Upgrades
Upgrade Cycles
Patches
Priority
Clinical Lab CLR
A Vendor
Pathology Informatics 2010John Gilbertson: Monday September 20
“Infrastructure”
Pathology Informatics 2010John Gilbertson: Monday September 20
LIS LIS
BillingADTResults
Batch
EMSI
RPDR
HL7
SpecimenInventory
Straw Aliquoter
Clinical Lab CLR
Accession
“DoneRacks”
?
Large scale clinical discard banking
Pathology Informatics 2010John Gilbertson: Monday September 20
No Developers Used
Pathology Informatics 2010John Gilbertson: Monday September 20
AP CP CP TM
Pathology Informatics 2010John Gilbertson: Monday September 20
AP CP Integration
Pathology Informatics 2010John Gilbertson: Monday September 20
AP CP Integration
AP CP
EMR
AP CP
EMR
We will work with our vendor
It will take a long time
We will not lose our informaticscard
Today
Pathology Informatics 2010John Gilbertson: Monday September 20
• It is not that we can’t do it, put that we chose not to• There is an opportunity cost to every project• The integration is more of a technical as opposed to a
domain expertise initiative• We think that departmental developmental resources are
better focused elsewhere
AP CP
Pathology Informatics 2010John Gilbertson: Monday September 20
• It is used by hundreds of physicians who increasingly require guidance
Order
Interpretation
LIS
Pre-analytic
Analytic
Reporting
• The clinical laboratory is perhaps the most powerful, most complex diagnostic tool on earth
• We need better tools for clinical context & “presence” at ordering and interpretation
Pathology Informatics 2010John Gilbertson: Monday September 20
Anatomic Pathology is beset buy– Increased volume– Increased Complexity
The AP Laboratory high “variation” and very low efficiency
Pathology Informatics 2010John Gilbertson: Monday September 20
• Meanwhile over the next several years ~ 3 Billion people will be looking for pathology services
Pathology Informatics 2010John Gilbertson: Monday September 20
The pathology department has three missions….
…The LIS only supports one
Pathology Informatics 2010John Gilbertson: Monday September 20
• The will likely be a fight for resources sometime in the future
• Understanding and documenting the value of pathology in health care…
Pathology Informatics 2010John Gilbertson: Monday September 20
Enterprise Systems
AP CP LIS
POE EMR ADT PACS70/70/3/0
Communication
Efficiency
Quant Value
Teaching&
Research
Departmental Sub SystemsPACS MOL DASH LH
Pathology Informatics 2010John Gilbertson: Monday September 20
Summary
• When the mission, workflows and data structures of two laboratory activities become similar there are compelling reasons to integrate under a single system
• AP and CP are converging in a number of ways, and it is time to think about integration of the LIS systems. Both the convergence and the integration will take time
• We have moved our AP and CP platforms to a single vendor to facilitate this convergence
• While not the only approach, homogeneous integration allows departments to focus developmental resources in other areas
Pathology Informatics 2010John Gilbertson: Monday September 20
Integration, systems and standards
• The importance of open AMSI standards in the integration of AP / CP and the LIS of future
• The model of DICOM and IHE
• Asset IDs
• Report (data) Archives
• Image Archives
• HIS – LIS, Device Interfaces….