Healthcare Technology Featured Article

November 07, 2016

Best of Breed or Monolithic: The Pendulum Swings


My first paying job in hospital-based software was the summer of 1969, working in the information technology (IT) department of the Lahey Clinic when they were still in Kenmore Square in Boston. One of my early projects was to help connect their accounts receivable system to their scheduling system. With the connection, a clerk could check to see if there were outstanding payments due from a patient trying to schedule an appointment. Since each module was initially built to stand on its own and not to coordinate with other modules, this was a bit of a challenge.

There is a creative tension that exists in the world of Hospital Information Systems, boiling down to two competing philosophies: (1) Best of Breed and (2) Fully Integrated.

In the Best of Breed world, hospital departments choose what they consider to be the best offering in each category of software, and trust that their IT department can set up the necessary interfaces to obtain, use and disseminate the data used and created by that software. Hospital IT departments have gone to great lengths to establish an environment of interoperability, using  the Health Level Seven (HL7) standards to provide a “comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.”

In the Monolithic world, a single software vendor is selected to provide all of the necessary software for a hospital. Modules from the monolithic vendor are given preference over anything from a third party vendor, even if that vendor has a far superior offering for a given department or task. Closed proprietary standards and lack of interface connections help to perpetuate the locked-down model of such monolithic systems.

Since I first ventured into hospital-focused software in 1969, I have seen the landscape of Hospital Information Systems go through many changes. Every few years, the pendulum seems to swing between Best of Breed and Monolithic. Over the last several years, the Monolithic philosophy has been quite prevalent, but I now have a strong sense that the pendulum is beginning to swing again. There are many factors driving this, including but not limited to:

  • An increasing awareness at the federal level that health information exchange is needed. The Office of the National Coordinator for Health Information Technology has set forth Principles and Strategy for Accelerating Health Information Exchange, which states that real-time interoperable health information is critical to transforming health care systems, regardless of the application or application vendor.
  • Continued growth and sophistication of the foundations of HIS interoperability, for example through the outstanding efforts of the initiative for Integrating the Healthcare Enterprise (IHE). As stated on their website, “IHE is an initiative ... to improve the way computer systems in healthcare share information ... Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively.”
  • A growing recognition that it is unrealistic for a single monolithic vendor to be all things to all people.

Open standards and interoperability. I guess what’s old is new again.

About the Author

Dr. Jonathan Elion, MD, FACC, is a practicing board-certified cardiologist in Providence, RI and an Associate Professor of Medicine at Brown University. With over 40 years of experience in computing and more than 25 years of experience in medical computing and information standards, Dr. Elion has committed his career to innovations in high value services and healthcare delivery to maximize efficiency and cost effectiveness.  Jon is the founder of ChartWise Medical Systems, Inc., a Rhode Island based company that recently introduced ChartWise 2.0.  It is the first-to-market interactive software system designed to improve precision in quality clinical documentation and to support revenue assurance through its Web-based, comprehensive built-in expertise, electronic queries and robust on-demand reporting.




Edited by Alicia Young
By Special Guest
Dr. Jon Elion, MD, FACC and Founder/President of ChartWise Medical Systems ,





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