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Mercy Children’s Hospital
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Washington, DC
Electronic Information Integration Structure

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08/13/2008

Lisa Heavilon, David Robbins, Lisa-Marie Williams

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Mercy’s Children’s Hospital, Washington DC

Hospital Profile

Washington DC’s Mercy Hospital is a single, non-profit facility, sponsored by the Sisters of
Mercy. In the heart of our nation’s capital, it services Washington Metropolitan Area, which has
a population of 5.3 million, the eighth-largest metropolitan area in the country.1 The city boasts
the most diverse cultural and economic population in the country. Although Mercy shares the
DC area five other major hospitals, it is the only one devoted exclusively to the care of children.
It is dedicated to improving the lives of children through innovative programs, on-going research
and the latest treatment protocols for illness and disease. Our outstanding specially trained
physicians, nurses and clinical staff support an exceptional breadth of specialized programs. We
have JCAHO Hospital Accreditation with Commendation.

Mercy is a center of excellence in the following specialties.

Oncology. Because of research and treatment innovations led by Mercy Hospital and other
institutions, more than 75 percent of children and adolescents with cancer can now be cured.
Mercy performs bone marrow transplant and clinical trials of promising therapies. The nurse to
patient ratio on this unit is one registered nurse for every three patients. Staff on this unit depend
on our internal systems to provide systematic support for bone marrow transplants, the operating
room highly controlled chemotherapy drugs and rapid pathology results.

Infectious Disease. The Infectious Diseases unit offers consultation and diagnosis in the
management of children with any type of infectious disease. Laboratory assistance in diagnosis
of infections and service in the selection of antibiotics, antivirals or other forms of therapy are
also provided. This unit provides consultation for children with recurrent, chronic or unusual
infections, or any other indication of immune deficiency disease. This unit depends on the lab
system to provide state of the art bone marrow and stem cell processing. Additionally the staff
relies on our internal systems to provide systematic support for infection control monitoring and
communication with the CDC and local public health organizations.

Emergency Medicine. Our Level 1 Trauma Center has an attending physician, board certified
in pediatric emergency medicine, in the Emergency Department (ED) 24 hours a day to handle
emergencies, unscheduled visits and consultations that need immediate attention. This unit
depends on systematic support for labs, xrays, medications and blood.

Anatomic Pathology. Our Pathologists are responsible for diagnosing all tissue specimens
removed by the surgeons and conducting necropsy examination of the infants and children.
Specimens sent from other institution are examined and diagnosed. This unit depends on
automated labs and pathology.
Reconstructive Surgery. Our plastic surgeons are board certified with vast experience treating
children with a wide variety of plastic surgical issues, such as reconstructive and appearance-
related problems, as well as congenital conditions, such as cleft lip and palate and birthmarks.
Additionally they are experienced in surgical concerns resulting from trauma such as burns and
tumors. This unit depends on the tracking of tissue donors and systematic support of for the OR
suite.

Mercy is able to support these diverse and demanding specialties by designing a robust and
dependable infrastructure with highly integrated systems. This design is the capstone that will
grow with our patient population as well as our research and teaching programs for years to
come.

Systems Installed at Mercy

A new HIT system, Meditech, has recently been installed at Mercy Children’s Hospital
Washington, DC to help us improve the service we provide to patients. It is already making a
positive difference, below we will explain how.

CPOE - Meditech Physician Care Manager

Meditech has been recognized by both the Leapfrog Group and KLAS Consulting as one of the
leading vendors of CPOE. Meditech’s CPOE product is tailored for physicians and specifically
designed to be user-friendly. In fact, providers can place orders, identify adverse reactions, view
patient records, and calculate drug dosages based upon user-defined variables all from a single
screen.

Inboun Outboun Data Elements

d d
 (Pharmacy) Medication Order, Patient Identifier, Dosage,
Frequency
 (Lab) Lab Order, Order Qualifiers, Patient Identifier
 (Radiology) Imaging Order, Patient Identifier, Schedule
 (EMR) Order Log
 Updates to Clinical Decision Making Plugins
Access: Providers
Standards: Leapfrog compliant CPOE, CPT-4, NCPDP, LOINC, Proprietary Format to
EMR

Automated Pharmacy-Meditech

The Meditech Pharmacy application enables pharmacists, providers and nurses across the within
the enterprise to perform their daily activities efficiently and effectively by gaining immediate
access to clinical medication information, while ensuring safe, quality care for patients. Once the
clinician has placed the medication orders through CPOE, the pharmacy will profile those
medications on the patient’s EMAR. The Meditech Pharmacy application reduces clinical errors
with intelligent warnings, messages, and rejection notices. The application also minimizes lost
revenue with the option to charge the patient’s insurance for the medication when the nurse
documents that the medication has been administrated. Another Benefit of this system is that it
links easily with the AccuDose dispensing machine to maintain proper inventory levels and
charge the patient for the doses. The Pharmacy application meets HIPAA and The Joint
Commission guidelines.

Inboun Outboun Data Elements

d d
 (CPOE) Patient Name, MRN, Ordering Provider, Medication Name,
Dose, Route, Schedule, Start Date/Time, End Date/Time, Special
Instructions
 (Pharmaceutical Company) Medication Name, NDC code (National Drug
Code), Trade Name, Quantity, Dose, Route, Lot Number, Expiration Date,
Drug Interaction, Allergy, Side effects
 (AccuDose) Patient Name, MRN, Patient Location, Ordering Provider,
Order Number, Medication Name, Dose, Route, Schedule, Order Start
Date/Time, Order End Date/Time, Special Instructions
Access: Pharmacists and Pharmacy Techs. Nurses, Physicians and Quality (View Only)
Standards: HL7 outbound and inbound, HIPAA compliant, supports NCPDP(5.1) integration.

Med Stations - AccuDose

The hospital’s new automatic supply machines, AccuDose, are a step ahead in technology when
it comes to providing staff and employees with a manageable automated inventory and supply
management system. The system is being used to enhance the hospital’s inventory and supply
system; it also improves accountability of pharmacy inventory, compliance requirements helps
minimize errors and waste and its convenience allows nurses to focus more on patient care.

Inboun Outboun Data Elements

d d
 (Pharmacy) Patient Name, MRN, Ordering Provider, Medication Name,
NDC Code, Dose, Route, Schedule, Start Date/Time, End Date/Time,
Special Instructions
 (Meditech Master Staff) Clinician Name, User ID, Password
 (Pharmacy) Medication Name, NDC Code, Inventory Count
Access: Pharmacy Techs. Nurses, Pharmacists
Standards: HL7 outbound and inbound
Automated Lab-Meditech

The Laboratory functionality in Meditech’s Laboratory and Microbiology application improves

the speed and accuracy of lab work - from requisitioning through final reporting. Caregivers are
able to access accurate, up-to-the-minute lab results and reports quickly through Meditech and
therefore paper costs are reduced. Caregivers are also able to compare a patient’s current results
to previous results on the same screen. Another function of the Meditech Laboratory and
Microbiology application is that it has a function for integrated inventory management and
maintenance scheduling for laboratory instruments.

Inboun Outboun Data Elements

d d
 (Providers) Patient Identifier for Inquiry
 (CPOE) Radiology Orders
 (Providers) Radiology Results, Order Status, List of Orders,
Appointment Schedule
 (Revenue Cycle System) Charges, Patient Identifier, Medical
Necessity Check
 (EMR) Radiology Text Results, Digital Images
Access: Radiology Technicians, Providers, Nurses
Standards: CPT-4, DICOM, LOINC, Proprietary Formats Between Meditech Systems

Automated Radiology-Meditech

Meditech relies completely on HL7 to display the PACS and Amicas Images from Radiology to
the Meditech user.

Inboun Outboun Data Elements

d d
  (Other Labs) Specimen Identifier for multi-site tracking
 (Providers) Patient Identifier for Inquiry
 (CPOE) Lab Orders
 (Providers) Lab Result, Order Status, List of Orders
 (Pharmacy) Lab Results, Alerts
 (EMR) Lab Results
Access: Laboratory Technicians, Providers, Nurses
Standards: HL7 outbound and inbound, DICOM, LOINC, Proprietary Formats Between
Meditech Systems
Blood Bank - Meditech

Meditech’s Blood Bank application integrates donor, unit, and patient history information with
data in the EMR to ensure patient safety and reduce turnaround times. The application also
highlights abnormal test results, has the ability to manage the blood bank’s inventory, to manage
donor recruitment and scheduling, to report and track blood bank services within the facility,
this application also has other extensive reporting capabilities that are blood bank specific.

Inboun Outboun Data Elements

d d
 (Red Cross, Private Blood Banks) Facility ID, Lot Number, Product ID,
Blood Type, RH Factor, Expiration Date, Codabar/ISBT 128 code
 (Lab) Patient Name, MRN, Blood Type
 Manual Transfusion Record
Access: Blood Bank Manager, Blood Bank Workers, Nurses
Standards: HL7 outbound and inbound, Codabar and ISBT Symbology

Tissues and Biologics – TIMS

TIMS is a system that the hospital can use at the time the tissue or biologic arrives to the
hospital. It allows for the tissue or biologic to be “checked in” using an order number from a
packing slip, this method provides an easy way for the hospital to track the tissue or biologic if it
has to be recalled. The product goes onto storage where temperature is recorded regularly. The
OR tech can check on-line and check the information that has been entered into TIMS to see that
the tissue has arrived and ready the OR.

Inboun Outboun Data Elements

d d
 (Tissue Bank) – Tissue Donor Bank Number, Serial Number, Lot
number, Order Number, Description, Ordering Physician, Receive
Date/Time, Preparation Protocol, Buyer Code
 (Cryo Storage) – Donor Bank ID, Serial Number, Lot number, Ordering
Physician, Patient Name, MRN, Preparation Protocol, Storage Unit ID
 (OR) – Donor Bank ID, Serial Number, Lot number, Ordering Physician,
Patient Name, MRN, Preparation Protocol, Storage Unit ID
 (People Soft Financials) – Order Number, Patient MRN, Receive
Date/Time
Access: Receiving Dock, OR Tech, Scrub Nurse
Standards: HL7 outbound and non standard labels

Emergency Room and OR: PICIS

PICIS is used in the Emergency Room and in the Operating Room. This system is quite amazing
because it does so much. It can generate a complete electronic high-acuity patient record by
automating information collection from a variety of medical devices and from other clinical
systems within the hospital. It also does surgical scheduling and ER evaluations, assessments,
notations, treatment plans, and care protocols. It has a bed manager that streamlines
communication among admissions, nursing, bed control, and housekeeping to track bed
availability. It tracks the flow of patients entering and leaving the facility, immediately notifies
housekeeping when a room is ready for cleaning (using automated paging). The OR functions
tracks inventory and deals with OR scheduling.

Inboun Outboun Data Elements

d d
 (Lab) –Patient name, patient number, Physician name, Order Date,
Results, Date/Time)
 (Pharmacy) – Patient name, patient number, medication name, dose, route
 (Blood Bank) – Physician name, Order Date, Patient Name, patient
number
 (Radiology) – Patient name, patient number, Physician name, Order Date
 (Meditech Patient Record)
 Inventory Control -
 (People Soft Financials) – Order Number, Patient MRN, Receive
Date/Time
Access: Physicians, Nursing
Standards: HL7

Infection Control: Infection Monitor Pro

Infection Monitor Pro monitors incoming labs to identify infections. It is integrated with the HIS
and pharmacy system as well. It uses HL7, CCOW and is HIPAA compliant. It generates reports
for the CDC and local public health agencies. These reports are then faxed to the appropriate
agency.

Inboun Outboun Data Elements

d d
 Automated Lab results – Meditech (Result, Patient name, patient number,
Physician name, Order Date, Result Date)
 Automated Pharmacy – Meditech (Patient name, patient number, Current
Treatment for Result, Previous Treatments for expected results)
 CPOE – Meditech (Physician name, Order Date, Patient Name, patient
number)
 Hospital Acquired Infection reports to CDC and local public health
agencies
Access: Physicians, Nursing, Quality and Performance
Standards: HL7
Human Resources: People Soft

People Soft for Human Resources allows Mercy Children’s Hospital to manage information
about it employees, such as: employee number, name, position, home department, hire date,
home address, home phone number, and cell phone number.

Inboun Outboun Data Elements

d d
 Finance and Accounting: People Soft – employee number, employee
name, employee position, employee pay rate, employee base hours,
employee sick time, employee paid time off, tax rate, benefits
 Human Resources: People Soft – employee number, employee name,
employee position, employee department, hire date, home address, home
phone number, cell phone number
Access: Human Resources, Finance and Accounting
Standards: HL7

Finance and Accounting: People Soft

People Soft for Finance and Accounting allows Mercy Children’s Hospital to manage
information related to compensating employees for hours working along with charging them for
their benefits such as, dental, medical, vision and 403B.

Inboun Outboun Data Elements

d d
 AtStaff – Employee’s schedules, employee number, employee name
 Human Resources: People Soft – employee number, employee name,
employee position, employee department, hire date, home address, home
phone number, cell phone number
 Kronos- number of hours worked
 Finance and Accounting: People Soft – employee number, employee
name, employee position, employee pay rate, employee base hours,
employee sick time, employee paid time off, tax rate, benefits
Access: Human Resources, Finance and Accounting
Standards: HL7
Staffing: AtStaff

AtStaff's healthcare management software continuously aligns caregivers to the clinical demand
requirements of each patient, based on the daily input into the ClairVia demand management
solutions portion of the AtStaff system each day. This improves quality of care, patient safety
and patient throughput by ensuring that patients receive the exact, clinically appropriate level and
amount of staffing care from admission to discharge.

Inboun Outboun Data Elements

d d
 HCIS- Meditech (Patient name, patient number, patient location, patient’s
diagnosis, nursing interventions, medications, orders)
 Human Resources: People Soft – employee number, employee name,
employee position, employee department, hire date, home address, home
phone number, cell phone number
 Kronos - Employee’s schedules, employee number, employee name
Access: Human Resources, Nurse Managers, Clinical Unit Coordinators (CUC)
Standards: HL7

Payroll: Kronos

Every healthcare organization's mission is to deliver the highest quality patient care, and Mercy
Children’s Hospital is no different. However, it is increasingly more challenging in today’s
healthcare environment to balance labor cost, employee satisfaction and profit margins. Labor
accounts for the largest portion of operating costs in hospitals, and Kronos helps to manage those
costs by providing a clock in an out system for hourly hospital employees.

Inboun Outboun Data Elements

d d
 AtStaff – Employee’s schedules, employee number, employee name
 Finance and Accounting: People Soft – employee number, employee
name, employee position, employee pay rate, employee base hours,
employee sick time, employee paid time off, tax rate, benefits
 Kronos- number of hours worked sent to Finance and Accounting: People
Soft
Access: Human Resources, Finance and Accounting, Nurse Manager
Standards: HL7

Net Learning – Annual competencies

Net Learning offers a flexible method for Mercy Children’s Hospital employees to complete
comprehensive computer based learning such as annual competencies. Net Learning’s system
enables facilities to meet Joint Commission, HIPAA, and OSHA compliance standards and to
quickly create real-time performance reviews since managers can print out a “completion list”
for each of their employees. Managers are also able to add the hospital required annual
competencies with their own unit specific annual competencies. The employee completes each
competency by first reading through a Power Point presentation and then completing a 10-15
question test. Once the employee had scored at least 80% the competency moves from their “to
do list” to their “completions list.”

Inboun Outboun Data Elements

d d
 Human Resources: People Soft – employee number, employee name,
employee department
Access: Human Resources
Standards: HL7

Inventory Control: Home grown

Mercy Children’s Hospital has designed our own inventory control system. Our hospital has
multiple Omnicells in each patient care unit, when staff requires supplies, they can select the
patient and the supply and this action bills the patient as well as sends a message to the inventory
control database. Each unit has individually decided pars for each supply so that facilities
management knows when to restock each item. The OR PICIS system links with the hospital
inventory control database so that facilities management knows when to restock based on the
current level and pars.

Inboun Outboun Data Elements

d d
 Omnicell data – current level, pars
 OR PICIS data – current level, pars
 Reports to facilities management what to order for which departments and
what to restock for which departments
Access: Facilities Management
Standards: HL7

Revenue Cycle Management – Meditech Revenue Cycle

There are more advanced and extendable revenue cycle systems on the market than the Meditech
Revenue Cycle management tool. This tool was chosen, however, because it both meets the
needs of our hospital and will reduce the number of vendors we maintain a relationship with. The
Revenue Cycle software manages the full lifecycle of patient billing including issuing referrals,
generating bills/statements/claim forms, managing patient charges and the collections process.

Inboun Outboun Data Elements

d d
 (General Accounting) Daily and Monthly Billing Totals, Patient Refund
Amounts, Procedure Volume
 (HIM System) Patient Identifier, Procedures, Modifiers, Diagnosis, Date
of Service, Insurer
 (Payer) Eligibility / Benefit Response, Claim Status Response, Service
Review Response, Claim Payment Advice
 (Payer) Eligibility / Benefit Inquiry, Claim Status Request, Service
Review Request, Claim Payment Request
Access: Billing Office, Customer Support
Standards: CPT, HCPCS, ICD-9, National Drug Code (NDC) data sets. HIPAA X12N 820,
X12N 834, X12N 270, X12N 271, X12N 276, X12N 277, X12N 278, X12N 835, X12N 837,
NCPDP

Stakeholders
Each job function has a set of responsibilities which can be thought of as a series of logical
transactions. When a logical transaction is discussed, it is at a conceptual level and is divorced
from how that logical transaction is actually accomplished.

The logical transaction is accomplished through physical transactions. These physical

transactions describe what is being done to accomplish each logical transaction. These
transactions are generally completed through a vehicle of some sort; a vehicle can be a manual
process or it can be facilitated by using computer systems. When more than one computer system
is involved there is data that flows between the systems. Some of those data needs inform the
transaction, while others are created as a result of the transaction. These data flows are
structured and operated using pre-determined rules. These rules can be either proprietary or
standardized.

So, based on this framework, we break down our description into systems, logical transactions
and physical transactions governed by standards.

The complete list of stakeholders in a fairly large, multi-specialty hospital such as Mercy is
lengthy. Each group of stakeholders can be broken down into smaller groups. For example the
Providers themselves can be broken down in to physicians, nurses, assistants, physical therapists,
mental health professionals, etc. You can then further classify some of these groups by specialty
or job function.

The logical needs of the stakeholders can be effectively discussed at a high grouping level. These
logical transactions really are business needs of the stakeholders. We first break the stakeholders
down into two broad groups, internal stakeholders and external stakeholders, and then note the
high level entities in each.
The internal and external stakeholders will overlap. The same single stakeholder will have some
transactions that occur entirely within the hospital environment and a second set of transactions
that communicate with external stakeholders. The external stakeholders actually have another
full set of transactions that occur completely outside of the hospital but support the business
within the medical center.

Internal Stakeholders
The primary internal stakeholders are:

• Providers
• Internal Labs
• Internal Pharmacy
• Internal Radiology
• Operations
o Admin/Discharge
o Housekeeping
o Scheduling
• Billing
• Quality and Performance

Providers

The providers of health services are both the primary creator and user of information in the
hospital. The provider has logical associations with nearly every entity. The providers submit
orders to radiology and receive order results in the form of images back. A similar process
happens with the provider and the lab. Providers also submit prescriptions to the pharmacy for
their patients. Providers also communicate with Operations in the form of dietary request for
each of their patients. They share information with other providers within the hospital through
chart requests, consultations and referral requests.
Internal Labs

Internal labs are the recipients of test requests. The internal labs receive the orders and
communicate the results back to the providers. The internal lab has a business need of accessing
submitted orders, and a business need for communicating results back to the providers.

Internal Pharmacy

The pharmacy within the hospital receives and fills prescription orders from the providers. The
pharmacy has a business need for receiving, organizing, quality checking and filling orders.

Internal Radiology

The radiology office is responsible for receiving orders and returning the images to the
providers.

Operations

The operations department keeps the basic functions of the hospital working. They need to make
sure the right supplies are ordered and stocked. They need to manage cleaning and turning over
rooms. They need to make sure patients get fed the diet that their provider had ordered for them
and have access to entertainment.

Billing

The billing office fills the business role of managing the reimbursement process for the hospital.
Internally, the business office needs to receive the billable procedures from the providers, assign
the procedures standardized codes and route requests for reimbursement to the payers and
patients.

Quality and Performance

The Quality and Performance department is responsible for assuring proper reporting to Federal,
State and local regulatory agencies.

External Stakeholders
• Public Health
o Bio-Surveillance
o Research
• Accreditation Organizations
o Joint Commission
o Licensure
• Payers
 o Medicare
o Medicaid
o Private
• External Providers
• External Radiology
• External Lab
• External Pharmacy

Public Health

Public health agencies are the receivers of information from the hospitals. They receive disease
reports and vital statistics. This communication is generally one way, out of the hospital. Public
health agencies use information from the hospitals to monitor for disease outbreaks and gather
data for research.

Accreditation Organizations

Accreditation organizations are responsible for certifying both the hospital itself and verifying
the licensure of the practitioners that works for it. Examples of these licenses are: State Nursing
and Medical Licenses; CPR for Healthcare providers; Advanced Cardiac Life Support (ACLS);
Pediatric Advanced Life Support (PALS) and nurses with area specific certifications.

Payers

Payers include Medicare, Medicaid, private insurance companies and patients. The business need
for the hospital is to assure that they are reimbursed for the services they provide. Providers send
claims submissions, documents supporting those services, coordinate benefits and request status
information from payers. Payers respond with remittance, eligibility information, referrals and
claim status updates.

External Providers

External providers are practitioners who do not perform services at the hospital but share patients
in some way with that hospital. They may refer patients to the hospital or receive patients as
referrals from the hospital. External providers generally have a need to share charts with internal
providers. They need a copy of the relevant portions of a patient’s medical records and will
request or submit the results of tests from the lab.
External Radiology

Some specialty radiology functions are outsourced to external imaging centers. It may not be
cost effective for the hospital to own some of these devices so they outsource to an imaging
center. The internal providers need comparable access to the results of external radiology images
as they do internal images. The providers need to receive, view, organize and store images.

External Lab

Similar to the external imaging centers, the external labs need to receive orders and communicate
the results of those orders back to the hospital. In some circumstances the external labs will
coordinate reimbursement for the tests directly with the payers.

External Pharmacy

The external pharmacy is also similar to the external lab and external imaging centers. The
external pharmacy has a business need for receiving and managing prescription orders and
making them available for patients.

Conclusion
We have examined the design of many of the systems at Mercy Hospital. Internal and external
parties, their needs and system access have been identified. This mid-level view has touched on
the standards that these systems depend on and the integration that these standards make
possible. But no design is perfect. Although we sought to provide the most dependable,
standardized applications, not all functions could be systematized. There is still room for
improvement. In time paper based processes will be automated and new applications deployed.
We have ascertained that health care systems are constantly evolving, always improving, making
progress towards the common goal of improving health care delivery for all.
Appendix
Logical Data Flow of Transactions at Mercy are depicted in Figure 1.
Health Care Transactions – Logical Data Flow – Team 2

Pharmacy Lab

Prescription Order
Results

Claims / Pre-Auth / Benefit Check

Order
Payer Imaging
Remittance / Auth / Eligibility Results

Provider Disease Reports

Vital Statistics

Referral Chart
Requests Requests
Public
Accreditation Health
Organization Agency

External
Provider
 Figure 1

References
1 http://en.wikipedia.org/wiki/Washington,_D.C.