Journal: Review of Case Study

HIM 350 Case Study

Memorial Hospital is the largest trauma hospital in Manchester County. It consists of a main hospital

with 1,100 beds and six surrounding outpatient and specialty clinics. Memorial has been having a

difficult time sharing information and coordinating the care of its patients throughout the care cycle.

Currently, when a patient is discharged from the hospital, there is no way to track the patient’s

outcomes unless he or she revisits or is readmitted to the hospital. Additionally, when a patient comes

into Memorial as a new trauma patient or is transferred from a different hospital, it takes a great deal of

time to retrieve the patient’s medical information (past medical history, comorbidities, tests received,

current medications, etc.). These challenges have led to further issues such as duplicate tests, delays in

diagnoses, increased medication errors, more hospital readmissions, and decreased patient satisfaction.

In an attempt to combat these issues, Memorial Hospital recently joined a board that is leading an

initiative to create a new community-wide health information exchange (HIE) network. Greater

Manchester County is planning to build the Manchester Health Access Network (MHAN). The MHAN is a

nonprofit HIE system that would be governed by this local community public health board. The primary

objective for establishing the MHAN is to link all healthcare providers in the region and improve care

coordination via a secure network of electronic medical record systems. The MHAN would cover ten

boroughs with roughly 2.6 million people and would involve 1,950 providers in 12 member hospitals.

The community board received state funds to complete the project, but it is on a tight budget. The good

news is that all the providers in the network already store patient information electronically via

electronic medical records (EMRs) that consist of useful portals and interfaces that can quickly and

securely transmit information. However, while Memorial Hospital has a functional clinical data

warehouse (CDW) and an accompanying data dictionary that describes the collected data types,

formats, structures, and usage components, not all of the hospitals in the network do as yet. The

existence of the CDW and data dictionary will help facilitate interoperability, which is a key component

of the project.

The board will need to consider additional building blocks for interoperability as well. The standards that

MHAN would like to employ to achieve successful interoperability include those set forth by the

Nationwide Health Information Network (NHIN). The NHIN was established by the Office of the National

Coordinator for Health Information Technology (ONC) to provide recommendations for a common, web-

based platform for health information exchange. These recommendations involve securing HIE

transmission via services, protocols, standards, specifications and legal agreements such as the

following: standardized healthcare classifications and vocabularies like ICD-10-CM and SNOMED CT for

homogenizing meanings; HL7 for normalizing structures; laws, policies, and formal procedures for

regulating the transport of information; National Institute of Standards and Technology (NIST) standards

for controlling security; and application programming interfaces (APIs) for standardizing services.

Moreover, MHAN would like to use a master patient index (MPI) to ensure patient information is stored

in one record and is not duplicated. This MPI database makes certain that every patient is listed just

once within all hospital data systems.

The board must decide which model is the best to achieve interoperability and stay within budget all

while improving the efficiency, coordination, and quality of care. It must also determine what type of

data extraction techniques to use. The board can choose between centralized, federated/decentralized,

or hybrid models.

The centralized model will come with a single clinical data warehouse (CDW) that will be maintained by

the board but will also include a health information manager (HIM) from each member organization.

With this model, the patient information from each member hospital will be securely stored in and

transmitted from the CDW. Additionally, the information will be continually updated through interfaces

that connect each member hospital’s electronic health record (EHR) to the CDW using unique patient

identifiers. This model enables a high level of interoperability. However, it is very expensive to develop

and difficult to maintain.

The alternative is a decentralized or federated model. Rather than a single CDW, the federated HIE

model is composed of multiple CDWs belonging to each member hospital. Each member hospital

provides the central HIE-governing body with patient identifiers unique to the particular hospital, which

are then stored in an overall HIE registry. This registry will be filled with various unique types of

identifiers based on those given by each hospital. In order to obtain patient data in this type of HIE, the

member hospital must send a query to the overall HIE registry. The HIE registry has a record locator that

is searchable by patient identifiers, and the central governing body supplies the physical location of the

record to the requesting organization. The requesting organization must then request the patient

information from the facility that houses the information. The facility will then send the information via

some kind of secure service (e.g., VPN, email, portal). Although it is quicker to develop, less costly, and

easier to maintain, this decentralized model involves several steps to acquire data, is more time-

consuming, and is less interoperable than the centralized HIE model. Furthermore, it generates such

challenges as increasing the risk of duplicate health records due to CDWs existing at multiple locations

and hindering the consolidation of a patient’s complete, updated health record.

The hybrid model would be a combination of the two, likely including a centralized CDW interfacing with

data from each local remote CDW. The remote CDWs would transmit information to the centralized

CDW, all systems would use the same unique identifier, and the patient information would be directly

accessible to the representatives of each member hospital. The healthcare leaders on the MHAN central

governing board need to determine the best HIE architecture model to implement. Regardless of which

model is chosen, it appears that adopting the MHAN infrastructure is just what Memorial Hospital needs

to resolve its current challenges.