Doctor of Philosophy, Computer Science

Submitted to:

Computers have been used in Medicine since the early 1960s. Healthcare expenditures in the United States have broken the $1 trillion barrier and $3 trillion barrier Worldwide.

In the beginning Computers were used primarily to support the Patient Accounting and Billing Function. IBM had a System called SHAS --- Short for Shared Hospital Accounting System. In 1968 a company called Shared Medical Systems (SMS) took advantage of the need for Healthcare Providers to account, charge, and collect for services provided to Patients. SMS established a centralized data center with a SHAS type application that could be shared by other Healthcare Providers to support the Patient/Accounting and Billing Function. Today SMS is the second largest Health Information System (HIS) Application Vendor in revenues behind McKessonHBOC providing numerous applications in addition to the core "killer" Patient Accounting and Billing Application --- Which has maintained the same basic application architecture for the last 32 years.

Today there are 1700 Vendors of various sizes providing 70 computer-based Healthcare applications. Vendors range from the large HIS Vendors that provide a variety of applications to Application Specific Vendors (ASVs) who provide just a single application.

KO --- Keying Operations

G/L --- General Ledger

F/A --- Fixed Assets

MM/AP --- Materials Management/Accounts Payable

CA --- Cost Accounting

HR --- Human Resources

OP --- Order Processing

IE --- Interface Engine

PM --- Patient Management

EDW --- Enterprise Data Warehouse

RM --- Reimbursement Management

The typical Healthcare Provider Enterprise Model includes the following major processes.

• Patient Intake
• Primary Patient Care
• General Financial
• Reimbursement Management
• Specialized Patient Care
• Medical Records

The Patient Intake Process includes two major application types.

• Admission/Discharge/Transfer (ADT) --- Manages and controls the Patient's Length of Stay (LOS) or Care Episode.
• Patient Eligibility --- Manages and controls the Patient's Insurance eligibility and coverage.

Three major applications support the major patient care core processes.

• Order Processing (OP) --- Manages, coordinates, and controls orders to Care Specialists to provide Patient Care.
• Interface Engines (IE) --- Provides transaction integration between diverse multi-vendor and multi-platform Applications supporting the Enterprise.
• Patient Management (PM) --- Manages the Patient's Financial and Clinical Records.

• General Ledger (G/L) --- Manages and controls the Accounts of the Enterprise.

• Fixed Assets (F/A) --- Manages and controls the Fixed Assets of the Enterprise.
• Materials Management/Accounts Payable (MM/AP) --- Manages and controls all materials and equipment required to provide Patient Care. Coordinates Materials Management with Accounts Payable.
• Cost Accounting (CA) --- Manages and controls Costs at the micro level (Charge Code Level).
• Human Resources (HR) --- Manages and controls the Personnel Resources of the Enterprise. Includes the Personnel and Payroll Applications.

• Laboratory
• Radiology
• Other
• Pharmacy
• Physical Therapy
• Many Others

• Abstracting --- Extraction of key clinical and financial patient information from the Patient Management Systems.
• Coding --- Verifying and/or establishing the correct diagnosis and procedure codes for the Patient Care provided.
• Transcription --- Converting dictation of procedure notes, nursing notes, and discharge summaries to the official Medical Record hardcopy.
• Chart Management --- Managing the distribution, completion, and compliance of the official Medical Record.

Another view of the Healthcare Provider Enterprise Model as described by CSC514-1.PPT is analysis of the key transaction events that connect the Major Applications. Eight key transaction events dictate, control, and sequence the Patient Care Activity.

• Admission, Discharge, and Transfer (ADT) --- Transaction Event that registers (outpatients) or admits (inpatients). Also includes Transaction Events for Discharge and Transfer (i.e. Outpatient to Inpatient or ICU to Step-Down Nursing Unit).
• Order (ORDER)--- Transaction Event that places an order to a Specialized Patient Care Application (Department).
• Order Status (ORDER STATUS) --- Transaction Event that communicates the status of the order back to the placer of the order.
• Results (RESULTS) --- Transaction Event that returns the result of Patient Care provided by the order back to placer of the order.
• Charge (CHARGE) --- Transaction Event that generates the charge for the Patient Care provided as a result of the order and records the charge in the Patient Management Application.

• Abstract (ABSTRACT) --- Transaction Event that extracts key financial and clinical information from the Patient Management Application.
• Claims (CLAIMS) --- Transaction Event that extracts key billing information from the Patient Management Application and produces a claim that is sent to the Reimbursement Management Application.
• Remittances (REMIT) --- Transaction Event that sends an remittance advice from the Reimbursement Management Application back to the Patent Management Application to update the Patient's Accounts Receivable.

These eight key Transaction Events control the Patient's LOS or Episode (Outpatients) and occur in the sequence specified above. Moreover, the data element content of the key Transaction Events have been standardized by Healthcare System Standard's Organizations (Health Level 7 (HL7), Andover Work Group (AWG), MS Hospital Users Group (MSHUG), and many others)) and Federal and State Regulatory Organizations (Health Care Financing Association (HCFA)).

Two other major Transaction Events are required to account for the Patient Care Activity.

• Revenue (Revenue) --- Revenue generated from providing Patient Care, Fund Raising, and etc. is distributed to the General Financial Applications (Primarily G/L).
• Expense (Expense) --- Likewise Expense associated with providing Patient Care, Fund Raising, and etc. is distributed to the General Financial Applications (Primarily G/L).

Moreover, in the typical Healthcare Provider Enterprise not all of the Key Transaction Events are automated. As such, an Enterprise-Wide Keying or Scanning Operation is provided to process paper transactions. Notable among these are Charges originating from non-integrated Specialized Patient Care Applications.

The final piece of the Enterprise Model is an Enterprise Data Warehouse (EDW) which maintains an Enterprise-Wide Repository of clinical and financial information. The EDW is used as the primary reporting source for the Healthcare Provider Enterprise.

A number of Healthcare Software Vendors provide computerized applications to support the typical Healthcare Provider Enterprise Model described in CSC514-1.PPT above. These Vendors can be segmented into four major groups.

• Health Information System Vendors (HISVs) --- Vendors that provide multiple applications to support the core processes required by the Health Care Provider Enterprise.
• Application Specific Vendors (ASVs) --- Vendors that provide a single application to support a specific niche applications required by the Healthcare Provider Enterprise.
• Generalized Financial Vendors (GFVs) --- Vendors that provide Financial Applications that can be applied across Industries. These Vendors often provide Enterprise Resource Planning (ERP) Applications because they integrate the common Financial Processes which account for and control the enterprise specific processes of the Enterprise.
• Enterprise Reporting Vendors (ERVs) --- Vendors that provide EDW applications for Healthcare Provider Enterprises. Electronic Medical Record (EMR) Applications are included within this group.

Healthcare Provider Enterprises have been supported by computers for over 40 years. Originally the Applications that supported the Enterprise were "Department Oriented". The marketplace was controlled by a select small group of HISVs. The major applications that were provided included: Payroll; Patient Accounting and Billing; and General Ledger. The eight Key Transaction Events described in the Enterprise Model (CSC514-1.PPT) were paper that was passed from Department to Department and required conversion to computer readable form by the Central Keying Operation (KO).

In the early 1970's the El Camino Project was born in Northern California. Engineers from Lockeed Corporation applied disciplines learned in the Aircraft Industry to form a Company called Technicon (Now Eclypsis). Technicon introduced the concept of a "Patient Centered" Architecture which was based on a prescribed sequence of Transaction Events that controlled the Patient's LOS or Care Episode. The concept of an electronic Patient Order Event precipitated by an Admission Transaction Event that triggered an Order Status Event which triggered an Order Status Event which triggered a Results Reporting Event and generated an electronic Charge Event formed the logical foundation for the Primary Patient Care Process --- Core Application Process.

Originally IBM Mainframes provided the Hardware and System Software to support the limited Applications that were computerized. These were Centralized Host-Based Systems with a network of IBM Dumb Terminals utilizing custom software to allow light-pen User operation. Also in the early 1970's a joint effort was initiated between Massachusetts General Hospital and Digital Equipment Corporation to utilize DEC Minicomputers in a Local Area Network (LAN) like Architecture. The approach here was to use a Minicomputer for each Application or Function. The outgrowth of this Effort was an HIS Vendor called Medical Information Technology (Meditech). Meditech is a major HIS Vendor today which uses a network of Minicomputers and /or Microcomputer Servers as its Hardware Platform.

As Minicomputers gained universal acceptance, ASVs began to develop Applications to computerize Specialized Patient Care Processes --- Namely Laboratory, Radiology, and Pharmacy. Initially the HIS Vendors had controlled these Applications by either putting their Dumb Terminal or a Minicomputer in Laboratory, Radiology, or Pharmacy. However, as the Minicomputer Hardware Platform's application development capability improved along with the improvement of the UNIX Operating System, the number of ASVs began to proliferate.

Although the proliferation of ASVs expanded the Application Alternatives, it raised another important issue --- Integration. When the HIS Vendors supplied all the Applications represented by Enterprise Model (CSC514-1.PPT), integration was taken for granted. As the ASVs supplied Applications became more prevalent, integration issues began to dominate the Application Selection Process. As such a new Application called the Interface Engine was developed to ensure the communication of the Key Transaction Events between the various multi-vendor Multi-Platform Applications supporting the Enterprise. As the advent of the Minnicomputer precipitated the proliferation of ASVs, it also provided an ideal Hardware Platform to support the Interface Engine.

Moreover, the Health Level 7, Inc. (HL7) Healthcare Applications Standard Organization was formed. HL7 organized Healthcare Information Technology Professionals toward a common goal of defining a common data set for the Key Transaction Events described by the Enterprise Model (CSC514-1.PPT). As such the Healthcare Provider Enterprise could select an Application based on its Functionality rather than its incorporation in an HISVs Application Portfolio to ensure Integration. At this time the majority of Applications are HL7 compliant.

Microcomputers replaced Dumb Terminals. Microcomputer Servers replaced older Minnicomputers thus allowing for the migration and extension of Host-Based Systems to Client Server Systems. This event provided even more opportunity for the ASVs.

Another wave of change that has impacted Healthcare Application Development is Component Object Oriented Development (COOD). While HL7 provided standardization which promoted Application Integration, "Plug and Play" Application Interoperabilty was still lacking. The Andover Work Group (AWG) a Healthcare IT Standards Group extended the HL7 Standard by developing Object Component that implements the Standard. The Component called the Enterprise Integrator (EI) is incorporated into the receiving and the sending Application allowing for "Plug and Play" Application Interoperability.

Application of Internet Technologies to the Enterprise Model in the form of Intranets and Extranets have enhanced and extended the capabilities of the underlying Applications. The World Wide Web (WWW) combined with Industry Standard Browsers have provided universal access to Patients and other Enterprises that have Business to Business (B to B) relationships with the Healthcare Provider Enterprise. As such, Application Integration as described by the Enterprise Model (CSC514-1.PPT) has become independent of the physical location.

The application of Internet Technologies in the form of Intranets and Extranets have revolutionized the Healthcare Provider Enterprise Model. Industry Standard Browsers (Universal Clients) have provided universal access from within as well as from outside the Enterprise. Intranets and Extranets allow for the integration of Healthcare Applications without regard or concern for physical location. Business to Business (B to B) and Business to Customer (B to C) Applications are beginning to proliferate. A number of Healthcare e-Commerce Business have surfaced that take advantage of these new Internet Technologies. We see a greater opportunity to re-engineer Business Processes associated with the Healthcare Provider Enterprise Model than ever before over the last forty years.

Applications are being extended and enhanced to support the re-engineering of these Processes using Internet Connectivity and Component Object Oriented Development Technologies. The Healthcare Industry has become extremely competitive. Applying these new Information Technologies to achieve Strategic Advantage will determine which Healthcare Provider Networks succeed and which fail.

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