Chapter 9: Core Healthcare IT Solutions

Introduction

Core healthcare IT platforms form the operational backbone of modern healthcare delivery. These systems—ranging from electronic health records to patient engagement tools—enable clinical documentation, care coordination, patient access, and revenue integrity. For IT consultants, understanding the architecture, integration patterns, and vendor landscape of these solutions is critical for designing scalable, interoperable healthcare ecosystems.

The core platform market exceeds $50 billion annually, with EHR systems representing the largest share. Healthcare organizations increasingly seek integrated suites vs. best-of-breed point solutions, driving vendor consolidation and API-first architectures.

This chapter explores EHR/EMR systems, telemedicine platforms, patient portals, revenue cycle management, and decision frameworks for build vs. buy.

Electronic Health Records (EHR/EMR)

EHR Market Landscape

Market Share by Provider Type:

Core EHR Functions

Clinical Documentation:

• SOAP Notes: Structured templates with discrete data elements
• Flowsheets: Time-series vitals, I/O, labs for ICU/inpatient
• Problem List: ICD-10 coded active diagnoses
• Medication List: RxNorm coded, allergy checking, interaction screening

Computerized Provider Order Entry (CPOE):

• Medication Orders: Dose, route, frequency with CDSS alerts
• Lab Orders: LOINC-coded tests, auto-routing to LIS
• Radiology Orders: CPT-coded, integration with RIS/PACS
• Referral Orders: eReferral with FHIR ServiceRequest

Results Review:

• Lab Results: HL7 ORU messages, discrete values for trending
• Imaging Reports: HL7 ORU with embedded PDF, PACS viewer launch
• Pathology: Structured reports with SNOMED CT codes

Clinical Decision Support (CDS):

• Drug-Drug Interactions: Severity-ranked alerts (high, moderate, low)
• Allergy Checking: Cross-reactivity (e.g., penicillin → cephalosporin)
• Duplicate Order Prevention: Flag recent identical orders
• CDS Hooks: FHIR-based, context-aware recommendations (e.g., order-select)

EHR Integration Architecture

graph TD
    EHR["EHR CORE<br/>Clinical Documentation | CPOE | Results | Medication Mgt"]

    LIS["LIS<br/>(HL7 ORU)"]
    RIS["RIS/PACS<br/>(HL7 ORU, DICOM)"]
    PHARM["Pharmacy<br/>(HL7 RDE)"]

    INTER["INTEROPERABILITY LAYER<br/>FHIR API | HL7 v2 Interface Engine | Patient/Provider Dir"]

    PORT["Portal<br/>(FHIR R4)"]
    TELE["Telemedicine"]
    RCM["RCM"]

    EHR --> LIS
    EHR --> RIS
    EHR --> PHARM

    LIS --> INTER
    RIS --> INTER
    PHARM --> INTER

    INTER --> PORT
    INTER --> TELE
    INTER --> RCM

SMART on FHIR Apps

Use Cases:

• Specialty Calculators: eGFR, BMI, bleeding risk scores
• Clinical Guidelines: Evidence-based order sets launched in context
• Population Health: Risk stratification, gap-in-care identification
• Research: Patient cohort identification, eCRF pre-population

Example SMART App Launch Flow:

1. Clinician opens patient chart in EHR
2. Clicks "Growth Chart" SMART app
3. EHR redirects to app with OAuth authorization code
4. App exchanges code for access token (SMART scopes: patient/Observation.read)
5. App calls FHIR API: GET /Observation?patient=12345&code=29463-7 (weight)
6. App renders growth percentile chart
7. Clinician reviews, closes app (context ends)

EHR Implementation Considerations

Data Migration:

• Scope: Active problems, medication list, allergies (minimum); full history (ideal)
• Mapping: ICD-9 → ICD-10, legacy drug codes → RxNorm
• Validation: Reconciliation reports, clinical review of high-risk data (allergies, meds)

Workflow Design:

• Physician Champions: Co-design workflows, validate usability
• Optimization Cycles: Post-go-live sprints (reduce clicks, streamline documentation)
• Alert Fatigue: Tune CDSS thresholds, disable low-value alerts

Training:

• Role-Based: Physician, nurse, registration, billing (8-40 hours per role)
• Super Users: Embedded support during go-live (1:10 ratio)
• Ongoing: Monthly tip sheets, annual refresher training

Telemedicine and Virtual Care

Telemedicine Market

Market Size: $55 billion (2023), projected $185 billion by 2028 (CAGR 27%)

Modalities:

Telemedicine Platform Architecture

graph TD
    PAT["PATIENT INTERFACE<br/>Web Browser | Mobile App | Kiosk (rural clinic)"]
    TELE["TELEMEDICINE PLATFORM<br/>Video Engine | Screen Share | Virtual Waiting Room<br/>ePrescribe | Device Integration | Payment Processing"]
    INTEG["INTEGRATIONS<br/>EHR (HL7 ADT, FHIR) | Pharmacy (NCPDP) | Scheduling"]

    PAT --> TELE --> INTEG

Virtual Care Workflows

eVisit Workflow:

1. Patient Initiates: Mobile app, portal, or call center
2. Triage: Digital questionnaire, symptom checker (e.g., Buoy Health)
3. Scheduling: Real-time availability, same-day slots
4. Check-In: Identity verification (photo ID), consent, copay collection
5. Encounter: Video consult, provider documents in EHR (may be integrated or separate)
6. ePrescribe: Send Rx to patient's pharmacy (NCPDP SCRIPT)
7. Follow-Up: After-visit summary, patient portal message

Reimbursement Considerations:

Licensing and Credentialing

Interstate Practice:

• Interstate Medical Licensure Compact (IMLC): Expedited licensure across 40 states
• Nurse Licensure Compact (NLC): 41 states for RN/LPN
• Telehealth Parity: Some states allow out-of-state providers for established relationships

Credentialing:

• Credentialing by Proxy: Accept credentials from originating site (if CMS-approved)
• Telemedicine-Specific Credentials: Some hospitals issue limited telehealth privileges

Patient Portals and Engagement

Portal Features

Core Capabilities:

FHIR Patient Access API

21st Century Cures Act Requirement:

• Patient Access: API for third-party apps to access patient data (FHIR R4)
• Scope: USCDI v1 data classes (at minimum)
• Timeline: Enforced April 2021

API Scopes (SMART on FHIR):

• patient/Patient.read (demographics)
• patient/Condition.read (problems)
• patient/MedicationRequest.read (medications)
• patient/Observation.read (labs, vitals)
• patient/DocumentReference.read (clinical notes)

Example Third-Party Apps:

• Apple Health: Aggregate records from multiple providers
• CommonHealth: Share fitness data with EHR
• PicnicHealth: Compile medical records for research

Digital Front Door

Components:

graph TD
    START["Patient Arrives at Digital Front Door"]
    SYMP["SYMPTOM CHECKER / TRIAGE BOT<br/>'What brings you in today?'<br/>→ Urgency assessment (ED, urgent, PCP)"]
    MATCH["PROVIDER MATCHING<br/>In-network, specialty, location, hours"]
    SCHED["SELF-SCHEDULING<br/>Real-time availability, book instantly"]
    INTAKE["PRE-VISIT INTAKE<br/>Forms, insurance, copay, SDOH screening"]
    BOOKED["Visit Booked → Confirmation, Reminders"]

    START --> SYMP --> MATCH --> SCHED --> INTAKE --> BOOKED

Benefits:

• Reduce No-Shows: 20-30% via automated reminders, easy rescheduling
• Optimize Capacity: Fill last-minute cancellations
• Capture Data Early: Insurance, medications, reason for visit

Revenue Cycle Management (RCM)

RCM Workflow

graph LR
    FE["FRONT END<br/>Registration<br/>Scheduling<br/>Eligibility<br/>Prior Auth"]
    MC["MID CYCLE<br/>Charge Capture<br/>Coding (CPT, ICD-10)<br/>Claim Scrubbing"]
    BE["BACK END<br/>Claims Submit<br/>Payment Post<br/>Denials Mgmt<br/>A/R Follow-up"]

    FE --> MC --> BE

RCM Key Functions

1. Eligibility Verification:

• Real-Time Check: X12 270/271 transaction to payer
• Data Returned: Coverage status, copay, deductible, out-of-pocket max
• Timing: At scheduling, day before visit, check-in
• Goal: >98% verification before service

2. Prior Authorization:

• Triggers: Specialty drugs, advanced imaging (MRI, PET), surgery
• Workflow: Provider submits clinical documentation → Payer reviews → Approval/denial
• Automation: Rules-based auto-submission for predictable auths
• Denials: Appeal with peer-to-peer review

3. Charge Capture:

• Inpatient: Charge master linked to ADT (admit/discharge/transfer)
• Ambulatory: Provider documents encounter → codes assigned (CPT, ICD-10)
• Ancillary: Labs, imaging, procedures auto-billed via interfaces
• Leakage: Missed charges due to poor documentation (5-10% revenue loss)

4. Medical Coding:

5. Claim Scrubbing:

• Edits: NCCI (National Correct Coding Initiative) edits
• Required Fields: NPI, DX codes supporting medical necessity
• Clean Claim Rate: >95% target (no rejections/denials)

6. Payment Posting:

• ERA (Electronic Remittance Advice): X12 835 transaction
• Auto-Posting: Match payment to claim by patient account, DOS, billed amount
• Variances: Contractual adjustments, denials, patient responsibility

7. Denial Management:

Appeal Workflow:

1. Denial received via ERA (claim adjustment reason code)
2. Categorize by reason (clinical vs. administrative)
3. Gather supporting documentation (chart notes, policy, peer review)
4. Submit appeal within payer timeline (30-60 days)
5. Escalate to external review if denied again

RCM Metrics

RCM Technology Stack

Vendors:

CRM and Workflow Automation

Healthcare CRM Use Cases

1. Referral Management:

• eReferral: Digital referral from PCP to specialist (vs. fax)
• FHIR ServiceRequest: Structured referral with reason, urgency, attachments
• Loop Closure: Specialist sends consult note back to PCP (HL7 MDM or FHIR DocumentReference)
• Metrics: Referral leakage (patient never completes referral), time to appointment

2. Care Coordination:

• Care Plans: Structured goals, interventions, tasks (FHIR CarePlan)
• Task Assignment: Route tasks to care team (RN, social worker, pharmacist)
• Patient Outreach: Automated calls/texts for gaps in care (diabetic eye exam overdue)

3. Population Health:

• Registries: Patient cohorts by condition (diabetes, hypertension)
• Risk Stratification: High-risk patients for intensive case management
• Outreach Campaigns: Flu shot reminders, colorectal cancer screening

4. Patient Acquisition:

• Marketing Automation: Email campaigns, targeted ads (joint replacement)
• Lead Scoring: Predict conversion likelihood (scheduled visit)
• Attribution: Track referral source (physician, online, community event)

Workflow Automation

Business Process Management (BPM):

graph TD
    ADM["Patient Admitted<br/>(ADT A01 message)"]
    TRIG["Trigger Workflow:<br/>'High-Risk Fall Assessment'"]
    TASK["Create Task →<br/>Assigned to RN within 2 hours"]
    COMP["RN completes assessment in EHR<br/>(Morse Fall Scale)"]
    PREC["If High Risk →<br/>Auto-order fall precautions<br/>(bed alarm, yellow bracelet)"]
    CLOSE["Task closed,<br/>audit log captured"]

    ADM --> TRIG --> TASK --> COMP --> PREC --> CLOSE

Low-Code Platforms:

• Salesforce Health Cloud: CRM with care plans, patient 360 view
• Microsoft Power Automate: RPA for repetitive tasks (data entry, status checks)
• Camunda: Open-source BPMN engine for complex clinical workflows

Contact Center Integration

Omnichannel Routing:

• Phone: IVR, queue, ACD routing to appropriate team (scheduling, billing, clinical)
• Chat: Web chat, SMS, patient portal messaging
• Video: Virtual triage, behavioral health crisis line

Knowledge Base:

• FAQs: Self-service for common questions (how to access portal, billing)
• Clinical Protocols: Nurse triage algorithms (chest pain → ED, cough → telehealth)

Buy vs. Build Considerations

Decision Framework

Total Cost of Ownership (TCO) Analysis

EHR TCO Example (500-bed hospital, 5 years):

Hidden Costs of Build:

• Regulatory Burden: HIPAA audits, FDA registration (if SaMD)
• Security: Penetration testing, vulnerability management
• Technical Debt: Refactoring, legacy code maintenance

Extensibility and Ecosystem

Buy Advantages:

• App Marketplaces: Epic App Orchard, Cerner Code, Allscripts Developer Program
• SMART on FHIR: Vendor-agnostic apps without core system changes
• Partner Ecosystem: Integrations validated, supported by vendor

Build Advantages:

• Full Control: Customize workflows without vendor constraints
• Proprietary IP: Build competitive differentiation (e.g., unique analytics)
• Open Source Foundation: Leverage OpenMRS, OpenEMR, FHIR servers (HAPI FHIR)

When to Build

Criteria:

1. Unique Requirements: Workflow so specialized, no COTS fits (e.g., research hospital with novel data capture)
2. Strategic Differentiation: Software is core competitive advantage (e.g., payer's proprietary utilization management)
3. Resource Availability: Deep technical talent, executive support for multi-year investment
4. Control Imperative: Cannot tolerate vendor roadmap, lock-in, or pricing changes

Hybrid Approach:

• Core System (Buy): EHR from Epic, Cerner (proven, compliant)
• Custom Modules (Build): Unique analytics, patient engagement, decision support on top via APIs

Implementation Checklist

✅ EHR/EMR

• Vendor Selection: RFP with clinical, IT, financial scoring; demos with clinical staff
• Architecture: Define integration patterns (HL7 v2, FHIR, middleware), network topology
• Data Migration: Map legacy data, validate accuracy, clinical sign-off
• Workflow Design: Physician co-design, usability testing, optimize for clicks
• Training: Role-based, super users, go-live support (1:10 ratio)
• Go-Live: Big bang vs. phased, downtime plan, command center

✅ Telemedicine

• Platform Selection: Evaluate video quality, EHR integration, patient UX
• Licensing: Verify provider licenses for target states/provinces
• Workflows: Define triage, scheduling, documentation, ePrescribe flows
• Reimbursement: Confirm payer policies, billing codes (99202-99215, 99421-99423)
• Security: HIPAA-compliant platform, BAA with vendor, encryption in transit/rest

✅ Patient Portal

• FHIR API: Implement Patient Access API (USCDI v1, SMART on FHIR)
• Features: Prioritize by patient demand (scheduling, messaging, bill pay)
• Adoption: Email campaigns, check-in kiosks, provider encouragement
• Metrics: Track activation rate (>50%), engagement (logins/month), feature usage

✅ RCM

• Eligibility: Real-time verification (X12 270/271), integrate with scheduling
• Coding: CAC (computer-assisted coding) for high-volume codes, certified coders for complex
• Claim Scrubbing: NCCI edits, required fields, payer-specific rules
• Denial Management: Categorize by reason, root cause analysis, preventive workflows
• Analytics: Dashboards for Days in A/R, clean claim rate, denial rate by payer/provider

✅ Buy vs. Build

• TCO Analysis: Include hidden costs (regulatory, security, technical debt)
• Risk Assessment: Vendor viability, product roadmap alignment, exit strategy
• POC: Pilot with core use case, validate integration, gather user feedback
• Roadmap: Align vendor roadmap with strategic priorities, negotiate customization SLAs

Conclusion

Core healthcare IT solutions—EHR, telemedicine, portals, RCM—form the operational foundation of modern care delivery. Successful implementations require balancing clinical usability, interoperability, financial performance, and patient engagement.

Key Takeaways:

• EHR Selection: Market dominated by Epic, Cerner, Meditech; integration architecture (FHIR, HL7 v2) is critical
• Telemedicine: Permanent reimbursement post-COVID, but licensing and credentialing remain complex
• Patient Access: FHIR API mandate enables third-party app ecosystem, digital front door drives acquisition
• RCM: Clean claim rate >95%, denial management drives financial performance; automation (AI/RPA) reduces cost to collect
• Buy vs. Build: COTS wins on speed, compliance, interoperability; build only for strategic differentiation with adequate resources

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Next Chapter: Chapter 10: Advanced Technologies Transforming Healthcare