Chapter 4: Providers and Care Delivery Organizations

Introduction

Healthcare providers—hospitals, physician practices, clinics, and specialty facilities—are at the heart of patient care delivery. They face unique IT challenges: clinical workflows that cannot tolerate downtime, regulatory requirements for quality reporting, complex revenue cycle processes, and the need to coordinate care across multiple settings.

This chapter explores the diverse provider landscape, their specific IT needs, workflow patterns, and the technologies that enable efficient, safe, and profitable care delivery.

The Provider Landscape

graph TD
    subgraph CARE["PROVIDER CARE DELIVERY SETTINGS"]
        subgraph ACUTE["ACUTE CARE"]
            A1[Hospitals]
            A2[Emergency Departments]
            A3[Surgical Centers ASC]
            A4[Critical Care]
        end

        subgraph AMB["AMBULATORY"]
            B1[Physician Groups]
            B2[Urgent Care]
            B3[Retail Clinics]
            B4[Specialty Clinics]
        end

        subgraph POST["POST-ACUTE / SPECIALTY"]
            C1[Skilled Nursing SNF]
            C2[Rehab Facilities]
            C3[Home Health]
            C4[Hospice]
            C5[Long-Term Acute Care]
            C6[Behavioral Health]
        end
    end

Acute Care: Hospitals and Emergency Departments

Types of Hospitals:

Key Characteristics:

• 24/7 Operations: IT systems must have high availability (99.9%+ uptime)
• Life-Critical: Downtime can endanger patients
• Multi-Disciplinary: Physicians, nurses, pharmacists, lab, radiology, respiratory therapy
• High Regulatory Burden: CMS, Joint Commission, state health departments
• Complex Billing: DRG-based reimbursement, multiple payers

Typical IT Stack:

graph TD
    USERS["CLINICAL USERS<br/>Physicians | Nurses | Pharmacists | Lab | Radiology"]

    EHR["INPATIENT EHR (Epic, Cerner, Meditech)<br/>• CPOE • Clinical Documentation • Medication Admin<br/>• Care Plans • Flowsheets • Alerts/Reminders"]

    PHARM[Pharmacy<br/>System]
    LIS[Laboratory<br/>LIS]
    PACS[Radiology<br/>PACS]
    PORTAL[Patient<br/>Portal]

    INT[INTEGRATION ENGINE<br/>(Mirth, Rhapsody, Ensemble)]

    EDW[ENTERPRISE DATA WAREHOUSE<br/>• Quality Reporting • Population Health • Analytics]

    USERS --> EHR
    EHR -->|HL7 v2 ADT| PHARM
    EHR -->|HL7 ORM| LIS
    EHR -->|HL7 ORU| PACS
    EHR -->|FHIR API| PORTAL
    PHARM --> INT
    LIS --> INT
    PACS --> INT
    PORTAL --> INT
    INT --> EDW

Integrated Delivery Networks (IDNs)

Definition: Multi-facility health systems that provide coordinated care across settings (hospitals, clinics, post-acute).

Examples:

• Kaiser Permanente (39 hospitals, 700+ clinics, integrated payer)
• Mayo Clinic (3 major campuses, 200+ clinics)
• Cleveland Clinic (19 hospitals, 220+ outpatient locations)
• Ascension (140+ hospitals, 2,600+ care sites)

IT Challenges:

• Enterprise EHR: Single platform across all facilities
• Data Governance: Standardized workflows, order sets, documentation
• Interoperability: Seamless data flow between facilities
• Master Data: Centralized patient, provider, location registries

Benefits:

• Care Coordination: Shared care plans, referrals, patient history
• Economies of Scale: Negotiate better EHR pricing, shared IT staff
• Analytics: Enterprise-wide quality metrics, cost benchmarking

Accountable Care Organizations (ACOs)

Definition: Groups of providers who share financial and quality risk for a defined patient population.

Models:

• Medicare Shared Savings Program (MSSP): CMS ACO program
• Next Generation ACO: Higher risk/reward model
• Commercial ACOs: Contracts with private payers

IT Requirements:

Ambulatory Care: Physician Practices and Clinics

Practice Types:

Core IT Needs:

graph TD
    AMB["AMBULATORY EHR (Epic, athenahealth, eCW)<br/>• Scheduling • Registration • E&M Documentation<br/>• E-Prescribing • Lab Orders/Results • Patient Portal"]

    PM["PRACTICE MANAGEMENT (PM) / REVENUE CYCLE<br/>• Eligibility Verification • Charge Capture • Claims<br/>• Payment Posting • A/R Management • Patient Billing"]

    CLR["CLEARINGHOUSE (EDI)<br/>• 837 Claims • 835 Remittance • 270/271 Eligibility"]

    AMB --> PM --> CLR

Ambulatory-Specific Workflows:

• Appointment Scheduling: Online scheduling, reminders (SMS/email), waitlist management
• Pre-Visit: Insurance verification, prior authorization, forms (intake, consent)
• Visit: Check-in, rooming (vitals), provider encounter, checkout
• Post-Visit: Prescription refills, test result notification, follow-up scheduling
• Chronic Care Management: CCM billing codes (99490), RPM (99457/99458)

Ambulatory Surgery Centers (ASCs)

Characteristics:

• Outpatient Procedures: Same-day surgical procedures (orthopedic, GI, ophthalmology)
• High Throughput: Multiple operating rooms, fast case turnover
• Cost Efficiency: Lower overhead than hospitals

IT Requirements:

Post-Acute and Specialty Settings

Skilled Nursing Facilities (SNFs)

Characteristics:

• Post-Hospital Care: Rehabilitation after hospitalization
• Long-Term Care: Chronic condition management
• Medicare/Medicaid Heavy: CMS reimbursement via RUGs/PDPM

IT Needs:

Home Health Agencies

Characteristics:

• In-Home Care: Skilled nursing, PT/OT, aide services
• Episodic Payment: 30-day or 60-day episodes
• OASIS Reporting: Outcome and Assessment Information Set (required by CMS)

IT Challenges:

• Mobile EHR: Clinicians need tablets/smartphones for point-of-care documentation
• Offline Mode: Internet connectivity unreliable in some areas
• Visit Verification: EVV (Electronic Visit Verification) mandated by 21st Century Cures

Leading Home Health EHRs:

• Homecare Homebase
• WellSky (formerly Kinnser)
• Axxess

Hospice and Palliative Care

IT Needs:

• Hospice-Specific Documentation: Advance directives, comfort care plans
• Interdisciplinary Team: Coordination between nurses, social workers, chaplains
• Bereavement Tracking: Post-death family support

Key Personas and Their IT Needs

Clinical Personas

1. Physicians

Daily Workflow:

• Review patient lists, lab/imaging results
• Conduct patient encounters, document in EHR
• Place orders (medications, labs, imaging, consults)
• Respond to clinical alerts (critical lab values, drug interactions)
• Sign notes, prescriptions

IT Pain Points:

• EHR Burden: Excessive clicks, poor usability leading to burnout
• Alert Fatigue: Too many low-value alerts
• Fragmented Data: Information scattered across systems
• Interoperability Gaps: Can't see external records

IT Priorities:

• Usability: Intuitive interfaces, voice dictation, mobile apps
• Clinical Decision Support: Evidence-based order sets, diagnostic aids
• Data Access: Single view of patient across all encounters

2. Nurses

Daily Workflow:

• Medication administration (barcode scanning)
• Vital signs documentation
• Care plan updates
• Patient/family education

IT Needs:

• Mobile Workstations: Computers on wheels (COWs), tablets
• Barcode Medication Administration (BCMA): Prevent medication errors (5 Rights)
• Flowsheets: Trending vital signs, intake/output
• Handoff Tools: Shift reports, SBAR communication

3. Pharmacists

Workflow:

• Order verification, clinical review
• Drug interaction screening
• Formulary management
• Medication reconciliation

IT Systems:

• Pharmacy Information System: Order entry, inventory, dispensing
• Automated Dispensing Cabinets (ADCs): Pyxis, Omnicell
• IV Compounding: Gravimetric verification
• Integration: Bi-directional with EHR (orders in, dispense/admin back)

4. Laboratory and Radiology Technologists

Laboratory:

• LIS (Laboratory Information System): Specimen tracking, result entry, QC
• Analyzers: Automated chemistry, hematology, microbiology instruments
• Interface: HL7 ORM (orders from EHR), HL7 ORU (results to EHR)

Radiology:

• RIS (Radiology Information System): Scheduling, worklist, reporting
• PACS (Picture Archiving and Communication System): Image storage, viewing
• Modalities: CT, MRI, X-ray scanners send DICOM images to PACS
• Voice Recognition: Dragon Medical for dictation

Administrative and Financial Personas

1. Schedulers and Front Desk

Workflow:

• Appointment booking, insurance verification
• Check-in, copay collection
• Referral management

IT Tools:

• Scheduling Module: Calendar, waitlist, online booking
• Eligibility Verification: Real-time 270/271 queries
• Patient Registration: Demographics, insurance, consent forms

2. Coders and Billers

Workflow:

• Abstract diagnosis/procedure codes from documentation
• Assign CPT/ICD-10 codes
• Submit claims via clearinghouse
• Post payments, work denials

IT Needs:

• Computer-Assisted Coding (CAC): NLP to suggest codes from notes
• Charge Description Master (CDM): Hospital pricing database
• Scrubber: Pre-submission claim validation
• Denial Management: Track denial reasons, rework claims

3. Case Managers and Care Coordinators

Workflow:

• Discharge planning, SNF placement
• Utilization review (ensure medical necessity)
• Care gap closure (preventive screenings, medication adherence)

IT Systems:

• Care Management Platform: Task lists, risk stratification, outreach campaigns
• ADT Feeds: Real-time notifications of ED visits, admissions
• HIE Access: View external records, care summaries

IT and Biomedical Engineering

Responsibilities:

• EHR Support: User provisioning, training, troubleshooting
• Interfaces: HL7 integration, monitoring
• Medical Devices: IV pumps, ventilators, monitors (preventive maintenance, cybersecurity)
• Network: Separate VLANs for clinical, guest, medical devices
• Security: HIPAA compliance, incident response

Core IT Systems for Providers

1. Electronic Health Record (EHR) / Electronic Medical Record (EMR)

Market Leaders:

Core EHR Modules:

graph TD
    subgraph EHR["EHR CORE MODULES"]
        subgraph CLIN["CLINICAL"]
            C1[Patient Chart]
            C2[CPOE Orders]
            C3[Clinical Documentation]
            C4[Medication List]
            C5[Problem List]
            C6[Allergies]
            C7[Immunizations]
            C8[Care Plans]
            C9[Clinical Decision Support]
        end

        subgraph ADMIN["ADMINISTRATIVE"]
            A1[Scheduling]
            A2[Registration]
            A3[Referral Management]
            A4[Consent Management]
        end

        subgraph FIN["FINANCIAL"]
            F1[Charge Capture]
            F2[Coding CAC]
            F3[Claims Management]
            F4[Payment Posting]
        end

        subgraph REP["REPORTING"]
            R1[Quality Measures eCQMs]
            R2[Registries]
            R3[Public Health Reporting]
            R4[Dashboards & Analytics]
        end
    end

2. Ancillary Systems

Laboratory Information System (LIS)

Functions:

• Specimen tracking (barcode labels)
• Order management (priority, STAT orders)
• Result entry, verification, release
• Quality control (QC) and proficiency testing

Integration:

• HL7 ORM: Orders from EHR to LIS
• HL7 ORU: Results from LIS to EHR
• Instrument Interfaces: Analyzers send results to LIS (ASTM, proprietary)

Examples: Sunquest, Cerner PathNet, Epic Beaker

Radiology Information System (RIS) / PACS

RIS Functions:

• Exam scheduling, modality worklist (MWL)
• Radiologist reporting (voice recognition)
• Result distribution

PACS Functions:

• Image storage (short-term cache, long-term archive)
• Image viewing (radiologist workstations, physician viewers)
• DICOM routing

Workflow:

graph LR
    EHR[EHR<br/>Order]
    RIS[RIS<br/>Worklist]
    MOD[Modality<br/>Scanner]
    PACS[PACS<br/>Images]
    VIEW[Viewer<br/>Radiologist]

    EHR --> RIS --> MOD --> PACS --> VIEW

Vendors: GE Centricity, Philips IntelliSpace, Agfa, Change Healthcare

Pharmacy Systems

Inpatient Pharmacy:

• Order verification, clinical screening
• IV compounding, chemotherapy prep
• Automated dispensing cabinet (ADC) integration
• Controlled substance tracking (EPCS - Electronic Prescribing of Controlled Substances)

Outpatient Pharmacy:

• E-prescribing (Surescripts network)
• Formulary management
• Prior authorization (ePA)
• Prescription benefit manager (PBM) adjudication

Vendors: Omnicell, BD (Pyxis), McKesson, Cerner PharmNet

3. Revenue Cycle Management (RCM) Systems

RCM Workflow:

graph LR
    FE["FRONT-END<br/>• Pre-registration<br/>• Eligibility verify<br/>• Prior auth<br/>• Financial counsel"]
    MC["MID-CYCLE<br/>• Coding<br/>• Charge capture<br/>• Claim scrubbing<br/>• CDM updates"]
    BE["BACK-END<br/>• Claims submission<br/>• Payment posting<br/>• Denial mgmt<br/>• A/R follow-up<br/>• Patient billing"]

    FE --> MC --> BE

Key RCM Systems:

RCM Metrics:

4. Interoperability and Data Exchange

Health Information Exchange (HIE) Connectivity:

FHIR API Use Cases:

• Patient Data Access: Patient-authorized apps (Apple Health, Google Fit)
• Provider-to-Provider: Query for patient records at other facilities
• Payer Data Exchange: Claims + clinical data for care coordination
• Bulk Data Export: Population health analytics, research

Provider Workflow Patterns

Inpatient Workflow: Hospital Admission to Discharge

graph TD
    ADM["1. ADMISSION<br/>• Registration<br/>• Insurance<br/>• Bed assign"]
    ORD["2. ORDERS<br/>• Admission orders<br/>• Medications<br/>• Labs, Imaging"]
    RES["3. RESULTS<br/>• Lab values<br/>• Radiology reports"]
    CARE["4. CARE<br/>• Nursing documentation<br/>• Rounding"]
    DISC["5. DISCHARGE<br/>• Discharge summary<br/>• Prescriptions<br/>• Follow-up"]
    BILL["6. BILLING<br/>• Final coding<br/>• DRG grouping<br/>• Claim"]

    ADM -->|ADT^A01 message| ORD
    ORD -->|HL7 ORM to pharmacy, lab, radiology| RES
    RES -->|HL7 ORU from lab<br/>DICOM images, HL7 ORU rad reports| CARE
    CARE -->|Flowsheets, vitals<br/>e-MAR, Progress notes| DISC
    DISC -->|ADT^A03 message<br/>C-CDA to PCP, SNF<br/>NCPDP SCRIPT e-Rx| BILL
    BILL -->|ICD-10-CM/PCS<br/>MS-DRG<br/>837I claim|ADM

Ambulatory Workflow: Outpatient Visit

graph LR
    PRE["PRE-VISIT<br/>• Appointment scheduling<br/>• Insurance verify<br/>• Pre-registration<br/>• Forms (intake, consent)<br/>• Reminders (SMS, email)"]
    ENC["ENCOUNTER<br/>• Check-in<br/>• Vital signs<br/>• Provider exam<br/>• Orders (labs, imaging)<br/>• Documentation<br/>• Assessment/Plan<br/>• Coding (E&M, ICD-10)"]
    POST["POST-VISIT<br/>• Checkout<br/>• Prescription e-prescribing<br/>• Follow-up scheduling<br/>• Patient education<br/>• Billing (charge capture)<br/>• Payment (copay, balance)"]

    PRE --> ENC --> POST

Care Coordination Workflow

Transition of Care:

1. Hospital Discharge to Home:

   • Discharge summary (C-CDA) sent to PCP via Direct Protocol or HIE
   • Medication reconciliation (compare inpatient meds to home meds)
   • Follow-up appointment scheduled
   • Home health referral (if needed)

2. Referral to Specialist:

   • Referral order created in EHR
   • Prior authorization requested (if required)
   • Clinical information sent to specialist (C-CDA, FHIR)
   • Specialist sends consult note back to referring provider

3. Emergency Department (ED) Notification:

   • ADT^A04 (registration) message triggers care manager alert
   • Case manager reviews ED visit, contacts patient
   • Post-discharge outreach to prevent readmission

Architecture Considerations for Provider IT

High Availability and Disaster Recovery

Uptime Requirements:

Downtime Procedures:

• Paper Forms: Pre-printed order sets, documentation templates
• Downtime Medication Lists: Printed patient medication lists
• Read-Only Access: View-only mode for clinical reference
• Up-time: After recovery, manual entry of downtime documentation

DR Strategies:

• Active-Active: Dual data centers, load-balanced (Epic, Cerner support)
• Active-Passive: Failover to secondary site (RTO: 4-8 hours)
• Cloud-Based DR: AWS, Azure (faster RTO, lower cost)

Identity and Access Management

Single Sign-On (SSO):

• SAML/OAuth: Integrate EHR, PACS, pharmacy with AD/Azure AD
• Context Management: CCOW (Clinical Context Object Workgroup) - sync patient context across apps
• SMART on FHIR: Launch apps from EHR with patient context

Multi-Factor Authentication (MFA):

• Proximity Badges: RFID badges for workstation login
• Biometrics: Fingerprint, facial recognition (especially for pharmacy, controlled substances)
• Push Notifications: Duo, Microsoft Authenticator

Role-Based Access Control (RBAC):

Enterprise Master Patient Index (EMPI)

Challenge: Matching patients across systems without a universal identifier

EMPI Functions:

• Probabilistic Matching: Algorithm scores potential matches based on name, DOB, SSN, address
• Merge/Unmerge: Combine duplicate records, split incorrectly merged records
• Golden Record: Create a single "source of truth" patient record

Matching Criteria Example:

Thresholds:

• Auto-Match: >95% confidence → Automatically link
• Possible Match: 75-95% → Manual review queue
• No Match: <75% → Create new record

Device Integration

Medical Device Connectivity:

Integration Middleware:

• Capsule (Now part of Philips)
• Bernoulli (GE Healthcare)
• iSirona

Benefits:

• Reduce Documentation Burden: Auto-populate vitals in EHR
• Improve Accuracy: Eliminate manual transcription errors
• Enable Analytics: Continuous monitoring data for early warning scores

Key Performance Indicators (KPIs) for Providers

Operational Metrics

Clinical Quality Metrics

Financial Metrics

Implementation Checklist for Provider IT Projects

✅ Discovery and Requirements

• Stakeholder Interviews: Meet with physicians, nurses, schedulers, billers, IT
• Workflow Observation: Shadow users, document current state
• Pain Points: Identify inefficiencies, workarounds, user frustrations
• System Inventory: Catalog existing systems, interfaces, versions
• Data Flow Mapping: Document how data moves between systems

✅ Clinical Governance

• Clinical Advisory Board: Physician champions, nursing leaders, pharmacy
• Order Set Development: Evidence-based order sets, care protocols
• Clinical Decision Support (CDS): Drug interaction rules, alerts
• Documentation Templates: Standardize notes, flowsheets
• Downtime Procedures: Paper forms, read-only mode

✅ Technical Architecture

• Integration Strategy: HL7 v2 interfaces, FHIR APIs, batch files
• EMPI Strategy: Patient matching algorithm, merge/unmerge workflow
• Identity Management: SSO, MFA, RBAC
• High Availability: Redundancy, failover, DR plan
• Security Controls: Encryption, access controls, audit logs

✅ Data and Interoperability

• Terminology Standards: ICD-10, SNOMED, LOINC, RxNorm
• HIE Connectivity: CommonWell, Carequality, Direct Protocol
• FHIR API: US Core profiles, SMART on FHIR
• Data Warehouse: Analytics, quality reporting, population health

✅ Revenue Cycle

• Charge Capture Workflow: Link procedures to charges
• Coding: CAC, coding edits, DRG validation
• Claims Scrubbing: Pre-submission validation
• Denial Management: Root cause analysis, rework process
• Patient Financial Experience: Estimates, payment plans, online billing

✅ Training and Change Management

• Training Plan: Role-based training (physicians, nurses, schedulers)
• Super Users: Identify champions, train-the-trainer
• Communication: Regular updates, town halls, newsletters
• Go-Live Support: 24/7 command center, elbow support, rapid response
• Post-Go-Live: Stabilization period (2-4 weeks), continuous improvement

✅ Quality and Compliance

• eCQM Validation: Test quality measure extraction
• MIPS Reporting: Configure quality, cost, improvement activities
• ONC Certification: Ensure EHR meets certification criteria
• HIPAA Compliance: Privacy, security, breach notification

Conclusion

Providers are the backbone of healthcare delivery, and their IT needs are among the most complex and demanding in any industry. From life-critical inpatient EHR systems to high-throughput ambulatory practices, successful implementations require deep understanding of clinical workflows, robust technical architecture, and exceptional change management.

Key Takeaways:

• Workflow First: Technology must fit clinical workflows, not the other way around
• High Availability: Downtime endangers patients; design for 99.9%+ uptime
• Interoperability: HIE connectivity, FHIR APIs, and standards adoption are essential
• Revenue Cycle: Clean claims and efficient A/R processes are critical for financial health
• Clinical Engagement: Physician and nurse buy-in determines success or failure
• Training and Support: Go-live is just the beginning; plan for ongoing optimization

In the next chapter, we'll explore Payers and Health Insurance, examining the unique IT needs of health plans, claims processing, and risk management.

Next Chapter: Chapter 5: Payers and Health Insurance