1. Perspective Ramez Shehadi
Dr. Walid Tohme
Jad Bitar
Fit for Purpose
Developing Enterprise-
Wide Electronic
Medical Records

2. Contact Information
Beirut
Ramez Shehadi
Partner
+961-1-985-655
ramez.shehadi@booz.com
Dr. Walid Tohme
Principal
+961-1-985-655
walid.tohme@booz.com
Jad Bitar
Senior Associate
+961-1-985-655
jad.bitar@booz.com
Booz & Company

3. EXECUTIVE As healthcare providers transform their business models to
focus on delivering a continuum of care for their patients,
SUMMARY
they are under increasing pressure to ensure that critical
information is available in the right place and at the right time.
Although traditional hospital information systems worked
well in a world in which patients’ needs could be met within
a single facility, that technology is evolving to connect the
growing network of facilities and caregivers that are engaged
in serving a multitude of interconnected patient needs.
These constellations of facilities and Knowing which technology fits best
providers are increasingly supported for each organization requires a care-
by a large set of healthcare technol- ful analysis of which core functions
ogy systems—all of which rely on a facility needs, what requirements it
electronic medical records (EMRs). has for clinical information systems,
By creating a holistic view of patient- how the capabilities of existing facili-
related information, EMRs bring the ties can be leveraged and integrated
promise of enhanced quality of care, into the network, and what con-
reduced medical errors and costs, and straints may be involved in executing
improved business performance for an enterprise EMR solution. In the
healthcare organizations. Today, a absence of this tailoring, organiza-
range of enterprise EMRs is available tions may end up with an EMR
to help bridge existing information solution that doesn’t fit their own par-
gaps, make healthcare institutions ticular needs—and the quality, cost
operate more efficiently, and improve savings, and performance that EMRs
patient satisfaction and outcomes. promise would be wasted.
Booz & Company 1

4. KEY HIGHLIGHTS
• A combination of competitive
pressures, patients’ demands,
technological advances, and
expanded rules and regulations is
forcing healthcare organizations
to migrate from stand-alone
facilities to integrated, full-service
provider networks.
• Traditional technology solutions
that helped stand-alone facilities
increase productivity and patient
satisfaction are evolving in order
to deliver an enterprise-wide view
of patient care that incorporates
multiple facilities and caregivers.
• Enterprise EMR solutions are
THE FORCES Prompted by these pressures,
providers have moved from a
credited with enhancing provider OF CHANGE discrete view of care, in which they
awareness of the full patient focus on specific episodes, to an
history, reducing administrative integrated approach in which they
costs, limiting errors and data aim to deliver a continuum of care
duplication, and contributing to to their patients from the cradle
increased patient satisfaction. to the grave. This new delivery
One of the major changes affecting model is transforming the industry
• When properly designed and the healthcare industry over the past by replacing single providers with
tailored to the specific needs of decade has been the transformation multiple-facility systems operating
each facility in the network, these of its delivery model. Care outcomes in integrated healthcare networks
enterprise solutions can bring are becoming an important (IHNs)—collections of various types
the promise of enhanced care, indicator of quality within the of healthcare delivery facilities that
reduced costs, and improved healthcare community, eclipsing include primary, secondary, and
business performance. volume of patients, length of stay, tertiary care (see Exhibit 1).
and occupancy rates. And because
today there are a greater number These networks help facilities achieve
of co-morbidities and a higher economies of scale by pooling their
prevalence of chronic diseases, buying power, eliminating duplicative
patients more frequently need to administrative and clinical roles,
be treated by different specialists consolidating technology applications
over a longer period of time. Stand- and other equipment across facilities,
alone facilities, with their increasing and centralizing core business
complexity and the additional functions such as human capital and
time they require for reporting, finance. Through IHNs, facilities
are also struggling to comply attract a critical mass of cases, further
with new regulatory demands. developing their clinical expertise.
Regulations and standards, such as From a care perspective, IHNs offer
the Health Insurance Portability and a more holistic view of the patient
Accountability Act (HIPAA), have than was previously possible, along
been expanded over the last decade with better coordination across the
in order to cover different aspects of different levels of care.
healthcare delivery, such as access
to care, outcome of services, and This transformation of the delivery
confidentiality of patient information. model from stand-alone facilities
2 Booz & Company

5. to integrated healthcare networks in one place across multiple facilities making it easier for community
demands technology solutions that allows them to monitor and treat physicians to interact with hospitals:
link caregivers across an IHN, as patients across the continuum of care, With advances in medicine translating
well as outside of it. Such solutions and better leverage evidence-based into shorter hospital stays and more
give caregivers the access to patient medicine to increase the chances of outpatient treatment, hospitals are
data that permits them to effectively successful treatments in similar cases. increasingly looking to physicians to
collaborate and to make the right These technology solutions are also refer patients.
decisions about patients’ care. Giving helping hospitals create a competitive
providers access to all patient data advantage in the marketplace by
Exhibit 1
Different Levels of Technological Needs for Organizations in a Sample IHN
General Hospitals
Specialty Centers (Imaging Centers,
Reference Laboratories, Outpatient Clinics)
Primary Care Clinics
Note: The size of the object representing each organization illustrates the degree of functionality required of that organization’s EMR solution.
Source: Dr. Mohammad Al-Yemeni presentation at HIMSS IT Leadership Summit, Oman, November 2009; Booz & Company analysis
Booz & Company 3

6. EVOLVING TO This growing constellation of facilities
and providers is supported by a large
solutions that can support a provider’s
different network facilities by linking
AN ENTERPRISE set of healthcare technology systems modules to EMRs for additional
VIEW that rely on EMRs. Essentially, the
EMR is a single record that provides a
functionality. Basic EMR solutions
cover functions such as clinical
patient’s information across facilities, documentation and capture, clinical
and encounters. By using a unique dashboard, clinical workflow support,
patient identifier, an EMR is able to controlled medical vocabulary, and a
capture all of a patient’s data, such as clinical data repository. EMR solutions
age and sex, personal characteristics, allow hospitals to better manage their
laboratory and radiology results, patients and their facilities through
and current medication and allergies. one system, improving patient care
This record becomes the sole source and increasing productivity and
of information for a patient and patient satisfaction. To gain efficiencies
can be accessed by physicians, throughout the hospital, basic EMR
nurses, referring doctors, and other solutions interface with other clinical
authorized users—either within and administrative systems such as
medical facilities or remotely hospital information systems (HIS),
through a secure connection. It is the pharmacy information systems (PIS),
centerpiece and the unifying factor or lab information systems (LIS).
within an IHN’s integrated application
portfolio. An enterprise EMR goes a step
beyond the basic EMR solution
The emergence of IHNs in healthcare by comprising a set of clinical
delivery is changing the EMR functions and workflows that
landscape, as hospitals now interact are fully integrated to provide
with a number of facilities and other patient information throughout the
outside partners. As a result, the stand- continuum of care (see Exhibit 2).
alone EMR needs to be replaced with
Exhibit 2
EMR Solutions Offer Varying Degrees of Functionality Based on Organizations’ Needs
BASIC ENTERPRISE EMR FULL ENTERPRISE EMR
Interdisciplinary
Care Plan
t on
or isi
Ph form
pp ec
In
ar a
Su al D
m tio
ac n
ic
Scheduling Scheduling
y
lin
C
Admission, Admission,
Single Single
Discharge Discharge
& Transfer Patient Record & Transfer Patient Record
Nurse Patient
Triage Billing
Referral Referral
Registration Registration
Tracking Tracking
Enterprise Enterprise
En an d
er ci ize
Master Master
Ad R
M inis ord
rd ysi ter
Patient Index Patient Index
ed tra
m ec
try
Ph pu
ic tio
om
al n
C
O
Clinical
Documentation
Note: There are also interim options between the basic EMR solution and the full EMR solution, which can be customized for individual facilities’ needs.
Source: Booz & Company
4 Booz & Company

7. Although solutions vary from vendor make more-informed decisions decreased duplication, and the
to vendor, an enterprise EMR typically based on all possible information elimination of manual entry, as
integrates the core functionality of a through a rules-based engine. For well as a reduction in multiple
stand-alone EMR (i.e., a single patient example, a CDSS will assist caregivers requests for similar diagnostics
record) with various additional by checking for drug interactions, • Increased patient satisfaction due
modules, including: incompatibilities among prescribed to improved service delivery time
drugs, and a patient’s allergy profile and increased caregiver focus on
Enterprise master patient index and dosage errors. patients
(EMPI): This module ensures that
the patient database is normalized The clinical and administrative To achieve all of these benefits, an
by eliminating duplicate records benefits of an enterprise EMR enterprise EMR must be able to fully
and by preventing users from are widely recognized within the integrate with other existing clinical
creating them inadvertently. healthcare community: and administrative systems within
Typically this module will cross and the IHN. Often, systems exhibit the
match data elements from patient • Improved outcomes, because ability to communicate with one
demographics, registration data, and caregivers have access to a another through the exchange of data
encounter data from all clinical and patient’s full medical history such as patient demographics, but
administrative systems. they are not capable of exchanging
• Improved service, as the
critical decision support data,
automation of many low-value-
Computerized physician order including alerts. This failure arises
added tasks allows caregivers to
entry (CPOE): This system enables from the lack of integration between
focus more on patient care
caregivers to order laboratory and multiple solutions and providers,
radiology tests, evaluate patient • Fewer errors, thanks to and points to the absence of clear
standardization across interoperability standards. An
status, and document the actions
departments, analytics, and enterprise solution from a vendor,
they have taken.
smart systems which is typically integrated, can
Clinical decision support system • Reduced administrative costs solve these interoperability issues.
(CDSS): The CDSS helps caregivers due to increased productivity,
To achieve the full benefits of an
enterprise EMR, it must be able to
fully integrate with other existing
clinical and administrative systems
within the IHN.
Booz & Company 5

8. ONE SIZE DOES tightly integrated in a single
enterprise system.
doctors) that need a quick, affordable
solution which integrates the single
NOT FIT ALL patient record with a few additional
The key is to understand each modules. Some vendors claim to be
provider’s needs. During able to install such solutions very
Booz & Company’s recent rapidly (one practice per week),
development and implementation of including “go-live support.” In a
an IHN IT strategy, we analyzed the recent Booz & Company study for
Primary, secondary, and tertiary enterprise EMR requirements of nine a large IHN, we found that basic
facilities typically have different facilities within the IHN (see “Case EMR vendors combined elements
needs in terms of their EMRs. As Study: Tailoring an Enterprise EMR”). of the common hospital database,
such, these facilities place a high such as insurance information and
value on the ability to customize The facilities ranged from large patient data elements, with tailor-
enterprise EMR solutions to fit multi-specialty hospitals to midsized made functionality that met the
their individual needs. For example, specialty centers to small primary physicians’ specific demands (e.g.,
one facility may need a slimmed- care centers. Our review of specific area pharmacies, ordering privileges).
down EMR system with minimal facility requirements revealed that a Typical modules within a basic
scheduling capabilities, while basic EMR was not sufficient for all EMR solution include an EMR/
another will require a full-fledged facilities, but a full enterprise EMR single patient record system with
EMR system with the ability to was excessive for some facilities and minimal functionality, or a scaled-
control bed usage. would be too costly and complex to down version that includes just health
deploy and manage. To customize the information and data; registration
Vendors today are increasingly EMR solution, we went beyond the and scheduling; limited prescription
offering solutions with more two-level basic and enterprise models order entry; and laboratory and
powerful hardware and more and categorized the IHN facilities radiology results.
customizable software that are more into three groups according to their
responsive to healthcare providers’ EMR requirements: basic enterprise Partial Enterprise EMR
needs. Partnerships and acquisitions EMR, partial enterprise EMR, and
have helped a few vendors to offer enterprise EMR. This version is often used by specialty
enterprise EMR solutions that serve center facilities that require more
many users—referral management for Basic Enterprise EMR functionality than a small clinical
community doctors, CPOE and EMR office but have fewer and more
for caregivers, and revenue cycle The basic EMR solution is best suited specialized needs than a large, general
management for administrators— to small physician offices (around 10 multi-facility hospital because of their
6 Booz & Company

9. CASE STUDY: TAILORING AN ENTERPRISE EMR
A major healthcare investor was building an integrated healthcare network
encompassing several facilities, including an acute care center with around
400 beds and a portfolio of outpatient clinics and specialty services, such as
a diabetes clinic. The group wanted to understand how to create a centralized
patient view by integrating clinical applications across these facilities,
including EMR, radiology information systems (RIS), picture archiving and
communications systems (PACS), LIS, CPOE, CDSS, and PIS.
To define the most appropriate solution, we first identified key market trends in
clinical information systems along with best practices in deploying them. After
looking at top vendors’ offerings, caregivers’ needs, and the IHN’s portfolio,
we determined that EMR, HIS, PIS, CPOE, and CDSS should be offered as a
single enterprise solution, with RIS, PACS, and LIS considered separately. We
advised which capabilities should be offered centrally (e.g., order entry, image
archive) at the enterprise level, and which should remain local (e.g., specific
clinical systems). We then developed a target model for the IHN’s EMR that
specialization (e.g., diabetes clinic took into consideration each facility’s needs. For example, one of the facilities
or sports medicine center). Modules involved was a national reference laboratory focused on LIS that had no need for
that appear in this category include enterprise EMR functionality.
all those in the basic EMR category,
in addition to clinical decision One of the most challenging aspects of launching such a large enterprise
support, electronic image viewing, system is ensuring interoperability across the different systems. To that effect,
and the ability to order laboratory we designed an enterprise integration solution that makes sure all deployed
and radiology tests. Typically such a systems can interface seamlessly. We also developed an operating model
solution for specialty centers requires to ensure that the EMR is managed properly and that the different facilities’
significant effort to develop custom needs are taken into consideration as the system evolves. The operating model
functionalities as bolt-ons to out-of- included the team to manage the EMR once it was operational, the processes
the box modules. and policies to ensure its efficient operations (especially in capturing users’
needs), a budget that encompasses capital and operational expenditures to
Full Enterprise EMR deploy and manage the EMR, and a governance model that aligns the EMR with
each facility’s objectives as well as with the IHN’s overall objectives.
The full enterprise EMR is typically
Based on these recommendations, the team was able to articulate an integrated
aimed at large, multi-specialty
IT vision to the company’s senior management that helped them achieve their
hospitals, but tailored to the facility
vision of a paperless environment. The efficient exchange of clinical information
based on clinical and administrative
across systems offers enhanced quality of care by providing clinicians with a
workflows. This version comprises
holistic perspective on all their patients’ information and reducing the number of
the full suite of modules and
medical errors. The new system also lowers overall costs, including a significant
functionalities available. In addition
reduction in administrative costs.
to the functionality offered by the
partial enterprise EMR solution,
additional modules that would be
integrated include extended clinical
documentation, PIS, nurse triage,
patient billing, CPOE/order entry,
medical administration record, CDSS,
and EMPI.
Booz & Company 7

10. CONCLUSION By creating a holistic view of patient-
related information, EMRs promise
with the necessary EMR capabilities
is essential. Before investing time
enhanced quality of care and fewer and money in an enterprise EMR,
medical errors, reduced costs, and healthcare organizations should
improved business performance undertake a thorough review of their
for healthcare organizations. day-to-day needs to determine which
However, delivering a multi-facility, EMR solution fits the bill and what
multifunctional IT solution is a degree of customization is required.
complex task and the typical one- Without this tailoring, organizations
size-fits-all approach typically may end up with an EMR solution
offered by vendors is needlessly that doesn’t fit their own particular
time-consuming and costly. A needs—and the quality, cost, and
tailored approach that matches performance promise that EMRs
each healthcare organization’s needs bring will be wasted.
8 Booz & Company

11. Endnotes
1
For more information, please see Ramez Shehadi, Dr. Walid
Tohme, and Jad Bitar, “Healthy Links: Ensuring Interoperability in
Healthcare Delivery,” Booz & Company, 2009.
About the Authors
Ramez Shehadi is a partner Jad Bitar is a senior associate
with Booz & Company in with Booz & Company in
Beirut. He leads the information Beirut and a leader in the
technology practice in the information technology practice
Middle East. He specializes in with a focus on healthcare.
e-business and technology- He specializes in healthcare
enabled transformation, helping and business technology,
both private corporations and particularly strategy,
government organizations organization, operations, and
leverage technology, achieve innovation.
operational efficiencies, and
improve governance.
Dr. Walid Tohme is a principal
with Booz & Company in Beirut
and a leader in the information
technology practice with
a focus on healthcare. He
specializes in the management
and strategic use of technology
to enable the transformation
of healthcare organizations,
services, and infrastructure.
Booz & Company 9

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