Physicians Insist, Leave No Data Behind

“I want it all.” This sentiment is shared by nearly all of the clinicians we’ve met with, from the largest integrated health systems (IHS) to the smallest physician practices, in reference to what data they want access to once an aggregation solution like a data warehouse is implemented.  From discussions with organizations throughout the country and across care settings, we understand a problem that plagues many of these solutions: the disparity between what clinical users would like and what technical support staff can provide.

For instance, when building a Surgical Data Mart, an IHS can collect standard patient demographics from a number of its transactional systems.  When asked, “which ‘patient weight’ would you like to keep, the one from your OR system (Picis), your registration system (HBOC) or your EMR (Epic)?” and sure enough, the doctors will respond, “all 3”. Unfortunately, the doctors often do not consider the cost and effort associated with providing three versions of the same data element to end consumers before answering, “I want it all”.  And therein lies our theory for accommodating this request: Leave No Data Behind. In support of this principle, we are not alone.

By now you’ve all heard that Microsoft is making a play in healthcare with its Amalga platform. MS will continue its strategy of integrating expertise through acquisition and so far, it seems to be working. MS claims an advantage of Amalga is its ability to store and manage an infinite amount of data associated with a patient encounter, across care settings and over time, for a truly horizontal and vertical view of the patient experience. Simply put, No Data Left Behind.  The other major players (GE, Siemens, Google) are shoring up their offerings through partnerships that highlight the importance of access to and management of huge volumes of clinical and patient data.

Why is the concept of No Data Left Behind important? Clinicians have stated emphatically, “we do not know what questions we’ll be expected to answer in 3-5 years, either based on new quality initiatives or regulatory compliance, and therefore we’d like all the raw and unfiltered data we can get.” Additionally, the recent popularity of using clinical dashboards and alerts (or “interventional informatics”) in clinical settings further supports this claim. While alerts can be useful and help prevent errors, decrease cost and improve quality, studies suggest that the accuracy of alerts is critical for clinician acceptance; the type of alert and its placement and integration in the clinical workflow is also very important in determining its usefulness. As mentioned above, many organizations understand the need to accommodate the “I want it all” claim, but few combine this with expertise of the aggregation, presentation, and appropriate distribution of this information for improved decision making and tangible quality, compliance, and bottom-line impacts. Fortunately, there are a few of us who’ve witnessed and collaborated with institutions to help evolve from theory to strategy to solution.

Providers must formulate a strategy to capitalize on the mountains of data that will come once the healthcare industry figures out how to integrate technology across its outdated, paper-laden landscape.  Producers and payers must implement the proper technology and processes to consume this data via enterprise performance management front-ends so that the entire value chain becomes more seamless. The emphasis on data presentation (think BI, alerting, and predictive analytics) continues to dominate the headlines and budget requests. Healthcare institutions, though, understand these kinds of advanced analytics require the appropriate clinical and technical expertise for implementation. Organizations, now more than ever, are embarking on this journey. We’ve had the opportunity to help overcome the challenges of siloed systems, latent data, and an incomplete view of the patient experience to help institutions realize the promise of an EMR, the benefits of integrated data sets, and the decision making power of consolidated, timely reporting. None of these initiatives will be successful, though, with incomplete data sets; a successful enterprise data strategy, therefore, always embraces the principle of “No Data Left Behind”.

Are your KPIs creating a no-win situation?

Businesses that start implementing KPIs at a departmental level, without an enterprise wide effort to define a balanced set of key performance indicators, can unwittingly push their businesses into a no-win situation, as in these real-world scenarios:

• Customer Call Centers (often ahead of the curve as far as setting metrics) are tracking and incentivizing their call center agents to keep their call times short. Call center agents, in an effort to shave seconds off of each call, omit the crucial step of searching for a customer before entering a new one while logging interactions. Result: Duplicate customer records, which  may even be pushed to other systems, creating pain throughout multiple departments.
• In the push to meet monthly sales quotas, hyper-discounting  behavior becomes the norm among the sales team.  If the pricebook is complex and no one can get a true read on profitability, inappropriate discounting may be approved when management doesn’t have access to the right information to make an informed approval decision.
• Some businesses steer only by financial performance measures, but these are lagging indicators, and can seldom, in and of themselves, provide the required agility to succeed in rapidly changing situations.

The key, of course, is to strive for balance when implementing KPIs:

• Balance between leading (forward-looking) and lagging (backward-looking) indicators.
• Balance across stakeholder perspectives. The Balanced Scorecard as a starting point works well to achieve balance across core stakeholder viewpoints of financial, customer, process, and learning/growth.
• Balance across levels in your business hierarchy. Kaplan and Norton expanded on the balanced scorecard approach to help businesses drive metrics down through their organizations via strategy maps.
• Balancing speed metrics with quality metrics

Image courtesy of memory-alpha.org

The alternative to a balanced approach at the outset is usually a technology desparation move, such as manually cobbling together some key reports, manually trying to scrub out duplicate data, implementing undesirable or even temporary customizations to packaged programs. There’s usually at least one person in the IT department who’s enough of a Star Trek fan to want to reprogram that no-win scenario, just like the young James Kirk did with the Kobayashi Maru.

Doublin’ Down in Hard Times

Hard times are definitely here.  By this time everybody in IT-land has done the obvious: frozen maintenance where possible, put off hardware and software upgrades, outsourced where possible, trimmed heads (contractors, consultants, staff), pushed BI/CPM/EPM analytics projects forward, and tuned up data and web resources.

Now is the time to think outside the bunker!

IT needs to consider what will need to be done to nurture the green shoots poking through the nuclear fallout. All of the talking heads and pundits see them ( glowing with radiation or whatever) and  the utmost must be done to make sure they survive and grow or we shall all sink into the abyss!

This is the time to double down in IT (poker speak).  It is not about heavily hyped Cloud Computing or the latest must-have tech gadget, but about something much more mundane and boring: improving the business process.  There, I’ve said it, what could possibly be more boring?  It doesn’t even plug-in.  In fact (shudder!), it may be partially manual.

Business process is what gets the job done (feeding our paychecks!).  Recessions are historically the perfect time to revise and streamline (supercharge ‘em!)  existing business processes because it allows the company to accelerate ahead of the pack coming out of the recession.  In addition, recession acts as something of a time-out for everybody (I only got beatings, no time-outs for me), like the yellow flag during a NASCAR race.  When the yellow flag is out, time to hit the pits for gas and tires.  Double down when it is slow to go faster when things speed up again, obviously the only thing to do.

How? is usually the question.  The best first step is to have existing business processes documented and reviewed.  Neither the staff involved driving the process at the moment nor the business analysts (internal or consultants) are that busy at the moment.  That means any economic or dollar cost of doubling will be minimized under the economic yellow flag.  The second step is to look for best practice, then glance ouside-the-box to maximize improvement.  The third step is to look for supporting technology to supercharge the newly streamlined business process (I knew I could get some IT in there to justify my miserable existance!).

Small and medium businesses get the biggest bang for the buck (just picture trying to gas and change the tires on the Exxon Valdez at Daytona) with this strategy.  This process allows SMBs to leapfrog the best practice and technology research the Global 2000 have done and cut to the chase without the pioneer’s cost (damn those arrows in the backside hurt!).  Plus implementation is cheaper during recession ( I love to be on the buy-side).  The hardware, software, and integration guys have to keep busy so they cut prices to the bone.

The way forward is clear, IT only needs to lead the way, following is kind of boring anyway.

Change: Opportunity or Agony

“Embracing change” is a common mantra. However, experiencing change is a certain reality. With it comes a series of choices for everyone involved. Perhaps, the game of Jenga(tm) demonstrates these choices. As you may know, Jenga consists of wooden blocks shaped like tiny beams. The game starts with the beams stacked tightly, three per layer, alternating them vertically and horizontally. The object is to manually dislodge any block from the tower and place it on a new layer at the very top; expanding the tower upwards until it topples from lack of support below or is blown by a strong gust of wind.

Like Jenga, a business also grows using its assets, strengths and opportunities to build customers and market share.

To continue comparing Jenga to running an enterprise, perhaps you could use two different perspectives. The player of the game is like the executives of the organization, moving around structural blocks to expand the organization. This executive has a 360 degree view of the tower with the ability to stress test the blocks before dedicating them for the move; and can scope the environment for threats to the construction such as a shaky playing table or strong winds.

The contrasting view is that of the employees impacted by the move within an organization; perhaps visualized as tiny ants clinging to the moved block. These individuals have an intimate knowledge of this specific block. They know each dent, scratch and slight change in color. They know how snugly it fits against the neighboring blocks (the nitty-gritties necessary to accomplish a job) and how it informally interacts with others. But this internal perspective lacks the comprehensive view. From within the safety of the tightly-built fortress, workers may not sense the unstable foundation or feel the gusts.

As a block is selected those associated with it can be hurled into significant change. One’s first reaction at the vibration may be to grab on as hard as possible to the comfort of the block. Despite the desperation, it takes very little time to see that the forces are overpowering and a significant change is imminent. At this point, there are really two broad choices: resist or cooperate.

The consequences of the first choice, resistance, can lead to demise. To explain this, let’s consider the two forms of resistance – denial and defiance.

Denying the seriousness of the changing forces will severely cripple the industry. Current examples of underestimating the impact of an impending change are seen with traditional media. After reluctance, newspapers, magazines, local broadcast television and radio eventually adopted the Internet. Through applying their respective traditional medium’s paradigm to the Internet forum, they used it as the broadcasting and publishing vehicle. Newspapers, for example, started by replicating their publication online and updating the sites daily after street publication. Internet users expecting more immediate news discontinued their subscriptions to the physical newspapers and started viewing news on new Internet news sites that refreshed content frequently.

The other form of resistance, defiance, could cause alienation with peers who tire of negative attitudes. Excessive defiant behavior could lead to dismissal from those who perceive it as obstructive.

In contrast, the option of cooperation, could lead to quite different outcomes. If the change is from competitive or industrial pressure, adapting to the changes’ new opportunities could put you in the driver’s seat. Those Internet sites that enabled the viewer to customize content offer an example of seizing the opportunity to lead the industry. In Jenga, a beam moved to the top is exposed to uncomfortable drafts, unfamiliar elements and added visibility. The gusts and vulnerability could be threatening. Also, the fall is farther if knocked off. However, the experiences gained are the essence of leadership.

Another recent example is the trend to stop travel expense. Geographically dispersed employees, trainers and consultants can overcome this obstacle by mastering the various technologies to be productive remotely. As organizations adopt these methods, the paradigms of phone etiquette, correspondence and meeting presentations will morph into new standards. Those of us who have adapted will benefit professionally.

Other gloomy headlines tout that many companies have fallen, or as in Jenga, the towers have toppled. Those who have fallen into the heap are left with the challenge to adapt to a new reality. After some brushing off, skills can be applied to participate in a new tower. Existing knowledge and tools will be augmented by wisdom for the next cycle of industrial changes.

As professionals, we need to recognize that external forces will cause us to make some hard decisions. To react with leadership, we should seek opportunities in the changes, communicate the realities and urge others to accept them.

Budgeting from the trenches

Have you ever noticed how text books understate the budgeting process? They tend to gloss over the topic as four steps:

1. Determine revenues
2. Forecast expenses
3. Adjust
4. Communicate

Some text books suggest that that the process has iterations. This general outline of the process rings true, but its oversimplification makes the budgeting process sections meaningless when it comes time to map one out. I have found that undertaking the budgeting challenge is different between organizations. The process design is similar to perhaps how Generals draw up battle plans. The available personnel, supplies and equipment are assessed and the desired outcome is clear. However, the details of the approach are dependent on the specific terrain and rely on the latest tools and information. For this reason, organizations tend to see its budgeting strategy as unique.

Strategy is a fair term to use in budgeting as its outcome has a great deal at stake. Every staff member submitting input for calculations or making a request for funds has credibility on the line. Without complete information the profitability of a product, service, region or division is at jeopardy. And, day-to-day performance of the organization can be besieged from the pressure and time consumption when gathering intelligence from the field.

There is a point where this analogy between a battle plan and a budgeting process falls apart: That is, a battle will end and budgeting does not. A budget plan will play itself over and over. This exposes a point of vulnerability in the budgeting process as it was designed for a set of conditions that most likely has changed. It may no longer be sufficient to budget annually. Reporting requirements may change. Consolidations in the industry confuse the financial results. Or, new competitors, products, clients, regions and staff render the plan obsolete. When there is such a difference between the framework and reality, the budgeting framework cannot be trusted for strategic forecasting.

In the wake of the global financial crisis as organizations seek to maximize cash reserves, evaluate expenses and eliminate risk; the budget process surfaces as a key strategy. Those giving strategic input and making decisions have unprecedented pressures to assure accuracy and agility in cost cutting. Those who need to find opportunities for revenue are at a loss for validating an option’s viability. An organization is likely to forgo an opportunity without the ability to articulate its profitability, avoiding the risk of catastrophe.

Today’s battlefield is dynamic and most participants are deep in the trenches. We know that this gloomy economy will end and we intend to abandon the trench to take new ground. Our challenge is timing and selecting the method to move forward. While we are trenched, let’s review the budgeting tools and design a system giving us the agility to adapt to the changing markets, locate opportunities and operate effectively.

Cutting costs should not mean cutting revenue.

Image courtesy of BusinessWeek 9/25/08: "AmerisourceBergen's Scrimp-and-Save Dave"

The financial panic of late has caused a lot of attention on cutting costs – from frivolities like pens at customer service counters to headcount – organizations are slowing spending. Bad times force management to review every expense, and in these times obsess with them. Financial peace however has two sides – expense and revenue.

A side effect of cost cutting can be stunted revenue, over both the short and long terms. It is easier to evaluate costs than to uncover revenue opportunities, such as determining  truly profitable offerings and adapting your strategies to maximize sales. Also as difficult to quantify are the true loses in unprofitable transactions, and competitive strategies that can negatively impact your competition.

The answers to many of these questions can be  unearthed from data scattered around an organization, groking customers and instantly shared knowledge between disciplines. For example, by combining:

• customer survey data;
• external observations;
• clues left on web visits;
• and other correspondence within the corporation;

…an organization can uncover unmet needs to satisfy before the competition, and at reduced investment cost.

When external factors, like a gloomy job outlook, cause customers to change behavior, it is time to use all information at your disposal. Those prospects changing preferences for your offerings can provide golden intelligence about the competition or unmet needs.

Pumping information like this is the heart of business intelligence. Marketing and Sales can uncover the opportunity; however, it is up to the enterprise to determine how to execute a timely offering. Financials, human capital planning, and operations, work in concert to develop the strategy which requires forecasting data, operational statistics and capacity planning data to line up.

A good strategist views all angles, not just reducing cost.

Enterprise Information Strategy in 2009

If you’ve been in an IT-related role for more than 10 years, you’ve likely enjoyed the boom and bust the economy has provided. Healthier times enhance business capabilities in the form of multi-million dollar, cross organization implementations, while leaner times like these afford only the most critical needs to be fulfilled. So while the volatility wreaks havoc on your organization, one IT spend continues to stay strong. Strategy.

Strategy is a sound investment in prosperous times since the confirmation it provides protects the investment of larger scale initiatives. For example, a company committed to providing better customer service and market additional products into its customer base will undertake a 2 to 3 year set of tactical CRM initiatives. Success factors include the three usual suspects, ‘People, Process and Technology’, and aligning each with an ideal future state vision is critical.

A well executed strategy provides an education for stakeholders and builds consensus among individuals who may have never sat around the same conference room table before. It coalesces and prioritizes goals and objectives, drafts a future state architectural blueprint and describes business processes that will endure, and establishes a long term Road Map that orchestrates incremental efforts and illustrates progress.

So if strategy is a safe bet in better times, why invest in one now?  For executives I’ve met with most recently (Q3 and Q4 2008), a popular form of strategy is analogous to grandma’s attic. At some point, it may have occurred to you to look in grandma’s attic for something that may be useful, and if you’re truly fortunate, there may be something extremely valuable you hadn’t counted on. For C-level executives looking for ways to improve their bottom lines, the same treasure hunt exists in the corporate information they already possess.

To understand whether your enterprise information holds hidden treasures, explore these 10 questions with your organization. Answering ‘No’ or ‘Not sure’ to any questions that have exceptional relevance within your organization may suggest looking into an Enterprise Information Strategy enagement.

1. Do visionaries within my company have visibility to key performance indicators that drive revenue or lower costs?
2. Do I understand who my customers are and which products they own?
3. Am I able to confidently market additional products into my existing customer base?
4. Do I possess data today that would provide value to complimentary industries through new information based offerings?
5. Will my information platforms readily scale and integrate to meet the demands of company growth through acquisition?
6. Am I leveraging the most cost effective RDBMS software and warehouse appliance technologies?
7. Do I understand the systemic data quality issues that exist in the information I disseminate?
8. Do the organizations I support understand the reporting limitations of my current state architecture?
9. Is there an architectural blueprint that illustrates an ideal 2 to 3 year business intelligence future state?
10. Does my company have visibility to a Road Map that timelines planned projects and the incremental delivery of new business insights?

If Master Data Management is on your agenda

Start with Data Quality

Many organizations are currently working on Master Data Management (MDM) strategies as a core IT initiative. One of the fastest paths to failure for these large, multiyear initiatives is to ignore the quality of the data. This is a good post on other MDM design pitfalls.

Master Data Management (MDM) is defined as the centralization or single view of X (Customer, Product or other reference data) in an enterprise. Wikipedia says: “master data management (MDM) comprises a set of processes and tools that consistently defines and manages non-transactional data entities of an organization (also called reference data).” MDM typically is a large, multiyear initiative with significant investments in tools, with two to five times the investment in labor or services to enable the integration of subscribing and consuming systems. For many companies you are talking millions of dollars over the course of the implementation. According to Forrester, on average, cross-enterprise implementations range anywhere from $500K to $2 million and professional services costs are usually two dollars for every dollar of software license costs. When you consider integration of all your systems for bi-directional synchronization for customer or product information, the services investment over time can be up to five times the license cost.

At its simplest level, MDM is like a centralized data pump or the heart of your customer or product data (the most popular implementations). But once you hook this pump up, if you haven’t taken care of the quality of the data first, what have you done? You have just spent millions of dollars in tools and effort to pollute the quality of data across the entire organization.

Unless you profile the systems to be integrated, the quality of the data is impossible to quantify. The analysts who work with the data in a particular system have an idea of what areas are suspect (e.g., “we don’t put much weight in the forecast of X because we know the data is sourced from our legacy distribution system which has data ‘problems’ or ‘inconsistencies’”). The problem is that the issues are known at the subconscious level but are never quantified, which means a business case to fix the issues never materializes or gets funding to make improvements. In many cases, the business is not aware there is a problem until they try to mine a data source for business intelligence.
According to a study by the Standish Group, 83% of data integration/migration projects fail or overrun substantially due to a lack of understanding of the data and its quality. Anyone ever work on a data integration project or data mart or data warehouse that ran long? I have, and I’m sure most of the people reading this have too.

The good news is that data profiling and analyzing is a small step you can undertake now to prepare and position yourself for the larger MDM effort. With the right tools, you can assess the quality of the data in your most important data sources in as little as three weeks depending upon the number of tables and attributes. Further, it is an inexpensive way to ensure that you are laying the foundation for your MDM or Business Intelligence initiatives. It is much more expensive to uncover your data quality problems in user acceptance testing. Many times it is fatal.

Success of your MDM initiative depends on the quality of the data – you can profile and quantify your data quality issues now to proactively head off problems down the road and build a business case to implement improvement in your existing data assets (marts, warehouses and transactional systems). The byproduct of this analysis is that you can improve the quality of the business intelligence derived from these systems and help the business make better decisions with accurate information.

It’s the End of the World As We Know It!

The Holidays are a great for watching “End of the World” shows on the History Channel. They were a great comfort, actually almost encouraging, because all of the prophecies target 2012.  “The Bible Code II”, “The Mayan Prophecies”, and the Big 2012 Special compendium of End of the World scenarios, covering Nostrodamus to obscure German prophets, all agree that 2012 is the big one (Dec 21 to be exact!)  What a relief!, the rest of the news reports are trending to canned goods, shotguns, and gold by the end of the year.  We really have almost a whole 48 months before everything goes bang (I wasn’t ready anyway, procrastination rules!).

Unfortunately, we need to do some IT planning and budgeting for the new year and probably should have some thoughts going out 36 months (after that see the first paragraph).  As I discussed in a prior blog, the reporting, BI/CPM/EPM, and analytics efforts are the strongest priority; followed by rational short cost savings efforts.  All organizations must see where they are heading and keep as much water bailed out of the corporate boat as possible.  Easy call, job done! 

Then again a horrifying thought occurred to me, what if one of these initiatives should fail? (see my nightmares in prior blog posts on Data and Analytics).  I am not saying I’m the Mad Hatter and the CEO is the Red Queen, but my head is feeling a bit loosely attached at the moment.  Management cannot afford a failed project in this environment and neither can the CIO in any company (remember CIO=Career Is Over).

The best way to ensure sucessful project delivery (and guarantee my ringside lawn chair and six-pack at Armageddon in 2012) lies in building on best practice and solid technical architecture.  For example, the most effective architecture is to use a layer of indirection between the CPM application (like Planning & Budgeting) and the source data systems (ERP, Custom transactional).  This layer of indirection would be for data staging, allowing transfer to and from fixed layouts for simplified initial installation and maintenance.  In addition, this staging area would be used for data cleansing and rationalization operations to prevent polluting CPM cubes with uncontrolled errors and changes.  In terms of best practice, libraries and tools should be used in all circumstances to encapsulate knowlege rather than custom procedures or manual operations.  Another best practice is to get procedural control of the Excel and Access jungle of wild and wooley data which stands ready to crash any implementation and cause failure and embarassment to the IT staff (and former CIO).  When systems fail, it is usually a failure of confidence in the validity or timeliness of the information whether presented by dashboard or simple report.

CPM, EPM, and Analytics comprise and convey incredibly refined information and decisions of significant consequence are being made within organizations to restructure and invest based on this information.  The information and decisions are only as good as the underlying data going into them.  So skimping on the proper implementation can put the CIO’s paycheck at serious risk (Ouch!).

10 things you can do right now to improve your Enterprise Business Intelligence (BI) capabilities

1. Document examples of manulytics (manual analytics) activities to illustrate hidden fixed costs. Any BI investment initiative needs executive support and budget. You need to make a case for the investment to improve your BI capability and show the business a ROI (Return on Investment). The cost of the current manualytics activity needs to be documented to highlight the hidden fixed costs of the current way of doing business to help build consensus to make improvements.
2. Identify manualytics processes to be moved to production and automate.
3. Raise awareness of data as a corporate asset.
4. Enlist and cultivate a C-level executive sponsor for your Enterprise BI effort.
5. When the business asks a question that is difficult to answer – keep track of the level of effort expended to generate the information. How many analysts with spreadsheets are compiling information manually? When the answers accuracy are questioned, how much more time is spent proving the numbers are correct.
6. Development and document metadata wherever possible – Build in metadata requirements gathering into your SDLC – Create and standardize a process to capture table and column definitions and business logic into a standard format. Get tribal knowledge documented so that the business can continue to operate if people leave or move on.
7. Data Governance – develop a committee to work towards managing the data and IT assets of the organization.
8. Create/Assign data stewards for each of the source systems to agree on service level agreements for your source systems and resolve data quality issues.
9. Work to centralize your reference data – business hierarchies like department and product need to be centralized, agreed upon by all stakeholders – this is a task that can be driven by your corporate governance committee.
10. Don’t boil the ocean – Look for candidate pilot projects with a narrow scope to show quick wins to the business (90 day max.)
11. Work toward tool standardization – many organizations own one of each BI tool – work to standardize on one or two.
12. Build a Center of Excellence around BI and ETL – work to centralize your internal expertise for BI and ETL.

Well we ended up with twelve items, any one of which could fill a book or whitepaper and may be the subject of a future post.

As we work with different organizations, similar themes emerge. Every organization is different and your road to BI maturity is different from other companies. Sometimes it pays to have a fresh set of eyes come in and survey your current state to get you started on the right foot.