BIG DATA in Healthcare? Not quite yet…

Let’s be honest with ourselves. First –

“who thinks the healthcare industry is ready for Big Data?”

Me either…

Ok, second question,

“who thinks providers can tackle Big Data on their own without the help of healthcare IT consulting firms?”

Better yet,

“can your organization?”

“Big data” seems to be yet another catch phrase that has caught many in healthcare by surprise. They’re surprised for the same reason I am which was recently summed up for me by a VP of Enterprise Informatics at a 10 hospital health system – “how can we be talking about managing big data when very few [providers] embrace true enterprise information management principles and can’t even manage to implement tools like enterprise data warehouses for our existing data?” Most people in healthcare who have come from telecommunications, banking, retail, and other industries that embraced Big Data long ago agree the industry still has a long way to go. In addition vendors like Informatica who have a proven track record of helping industries manage Big Data with their technology solutions, still have yet to see significant traction with their tools in healthcare. There are plenty of other things that need to be done first before the benefits of managing Big Data come to fruition.

Have we been here before? Didn’t we previously think that EMR’s were somehow going to transform the industry and “make everything simpler” to document, report from, and analyze? Yes we now know that isn’t the case, but it should be noted that EMR’s will eventually help with these initiatives IF providers have an enterprise data strategy and infrastructure in place to integrate EMR data with all the other data that litters their information landscape AND they have the right people to leverage enterprise data.

Same can be said of Big Data. It should be relatively easy for providers to develop a technical foundation that can store and manage Big Data compared to the time and effort needed to leverage and capitalize on Big Data once you have it. For the significant majority of the industry the focus right now should be on realizing returns in the form of lower costs and improved quality from integrating small samples of data across applications, workflows, care settings, and entities. The number of opportunities for improvement in the existing data landscape with demonstrable value should be top priority to mobilize stakeholders to action. Big Data will have to wait…for now.

Please Stop Telling Everyone You Have an Enterprise Data Warehouse – Because You Don’t

One of the biggest misconceptions amongst business and clinical leaders in healthcare is the notion that most organizations have an enterprise data warehouse. Let me be the bearer of bad news – they don’t, which means you also may not. There are very few organizations that actually have a true enterprise data warehouse; that is, a place where all of their data is integrated and modeled for analysis, from source systems across the organization independent of care settings, technology platform, how it’s collected, or how it’s used.  Some organizations have data warehouses, but these are often limited to the vendor source system they’re sitting on and the data within the vendor application (i.e., McKesson’s HBI and Epic’s Clarity). This means that you are warehousing data from only one source and thus only analyzing and making decisions from one piece of a big puzzle. I’d also bet that the data you’ve started integrating is financial and maybe operational. I understand, save the hard stuff (quality and clinical data) for last.

This misconception is not limited to a single group in healthcare. I’ve heard this from OR Managers, Patient Safety & Quality staff, Service Line Directors, physicians, nurses, and executives.

You say, “Yes we have a data warehouse”…

I say, “Tell me some of the benefits” and “what is your ROI in this technology?”

So, what is it? Can you provide quantitative evidence of the benefits you’ve realized from your investment and use of your “data warehouse”?  If you’re struggling, consider this:

• When you ask for a performance metric, say Length of Stay (LOS), do you get the same results every time you ask independent of where your supporting data came from or who you asked?
• Do you have to ask for pieces of information from disparate places or “data handlers” in order to answer your questions? A report from an analyst; a spreadsheet from a source system SME, a tweak here and a tweak there and Voila! A number whose calculation you can’t easily recreate, that changes over time, and requires proprietary knowledge from the report writer to produce.
• What is the loss in your productivity, as a manager or decision maker, in getting access to this data? More importantly, how much time do you have left to actually analyze, understand and act on the data once you’ve received it?
• Can you quickly and easily track, measure and report all patient data throughout the continuum of care? Clinical, quality, financial, and operational? Third-party collected (i.e., HCAHPS Patient Satisfaction)? Third-party calculated (i.e., CMS Core Measures)? Market share?

Aside from the loss in productivity and the manual, time-consuming process of piecing together data from disparate places and sources, a true enterprise data warehouse is a single version of the truth. Independent of the number of new applications and source systems you add, business rules you create, definitions you standardize, and analyses you perform, you will get the same answer every time. You can ask any question of an enterprise data warehouse. You don’t have to consider, “Wait, what source system will give me this data? And who knows how to get that data for me?”

In the event you do have an enterprise data warehouse, you should be seeing some of these benefits:

1. Accurate and trusted, real–time, data-driven decision making
   • Savings: Allocate and deploy resources for localized intervention ensuring the most efficient use of scare resources based upon trusted information available.
2. Consistent definition and understanding of data and measures reported across the organization
   • Savings: Less time and money spent resolving differences in how people report the same information from different source systems
3. Strong master data – you have a single, consistent definition for a Patient, Provider, Location, Service Line, and Specialty.
   • Savings: less time resolving differences in patient and provider identifiers when measuring performance; elimination of duplicate or incomplete patient records
4. A return on the money you spend in your operating budget for analysts and decision support
   • Savings: quantitative improvements from projects and initiatives targeted at clinical outcomes, cost reductions, lean process efficiencies, and others
   • Savings: less time collecting data, more time analyzing and improving processes, operations and outcomes
5. More informed and evidence-based negotiations with surgeons, anesthesiologists, payers, vendors, and suppliers

In the end, you want an enterprise data warehouse that can accommodate the enterprise data pipeline from when data is captured, through its transformations, to its consumption. Can yours?

The Unknown Cost of “High Quality Outcomes” in Healthcare

“You were recently acknowledged for having high quality outcomes compared to your peers, how much is it costing you to report this information?”

I recently read an article on healthcareitnews.com, “What Makes a High Performing Hospital? Ask Premier”. Because so many healthcare providers are so quick to tout their “quality credentials” (yet very few understand how much it costs their organization in wasted time and money running around to collect the data to make these claims) and this article sparked the following thoughts…

The easiest way to describe it, I’ve been told after many times trying to describe it myself, is “the tip of the iceberg”. That is the best analogy to give a group of patient safety and quality executives, staffers, and analysts when describing the effort, patience, time and money needed to build a “patient safety and quality dashboard”  with all types of quality measures with different forms of drill down and roll up.

What most patient safety and quality folks want is a sexy dashboard or scorecard  that can help them report and analyze, in a single place and tool, all of their patient safety and quality measures. It has dials and colors and all sorts of bells and whistles. From Press Ganey patient satisfaction scores, to AHRQ PSIs, Thomson Reuters and Quantros Core Measures, TheraDoc and Midas infection control measures, UHC Academic Medical Center measures….you name it. They want one place to go to see this information aggregated at the enterprise level, with the ability to drill down to the patient detail. They want to see it by Location, or by Physician, by Service Line or by Procedure/Diagnosis. This can be very helpful and extremely valuable to organizations that continue to waste money on quality analysts and abstractors who simply “collect data” instead of “analyze and act” on it. How much time do you think your PS&Q people spend finding data and plugging away at spreadsheets? How much time is left for actual value-added analysis? I would bet you very little…

So that’s what they want, but what are they willing to pay for? The answer is very little. Why?

People in patient safety and quality are experts…in patient safety and quality. What they’re not experts in is data integration, enterprise information management, meta-data strategy, data quality, ETL, data storage, database design, and so on. Why do I mention all these technical principles? Because they ALL go into a robust, comprehensive, scalable and extensible data integration strategy…which sits underneath that sexy dashboard you think you want. So, it is easy for providers to be attracted to someone offering a “sexy dashboard” that knows diddly squat about the foundation, or what you can’t see under the water, that’s required to build it. Didn’t anyone ever tell you “if it sounds too good to be true, it is!?”

Why EMR’s Are Not Panacea’s for Healthcare’s Data Problems

So, you’ve decided to go with Epic or Centricity or Cerner for your organization’s EMR.

Think your EMR is Hamlin's Wizard Oil?

Good, the first tough decision is out of the way. If you’re a medium to large size healthcare organization, you likely allocated a few million to a few hundred million dollars on your implementation over five to ten years. I will acknowledge that this is a significant investment, probably one of the largest in your organizations history (aside from a new expansion, but these implementations can easily surpass the cost of building a new hospital).  But I will argue: “Does that really mean the other initiatives you’ve been working should suddenly be put on hold, take a back seat, or even cease to exist?”

Absolutely not. The significant majority of healthcare organizations (save a few top performers) are already years and almost a decade behind the rest of the world in adapting technology for improving the way the healthcare is delivered. How do I know this? Well, you tell me, “What other industry continues to publicly have 100,000 mistakes a year?” Okay, glad we now agree. So, are you really going to argue with me that being single-threaded, with a narrow focus on a new system implementation, is the only thing your organization can be committed to? If you’re answer is yes, I have some Cher cassette tapes, a transistor radio, a mullet, and some knee highs that should suit you well in your outdated mentality.

An EMR implementation is a game-changer. Every single one of your clinical workflows will be adjusted, electronic documentation will become the standard, and clinicians will be held accountable like never before for their interaction with the new system. Yes, it depends on what modules you buy – Surgery, IP, OP, scheduling, billing, and the list goes on. But for those of us in the data integration world, trying every day to convince healthcare leaders that turning data into information should be top of mind, this boils down to one basic principle – you have added yet another source of data to your already complex, disparate application landscape. Is it a larger data source than most? Yes. But does this mean you treat it any differently when considering its impact on the larger need for real time, accurate integrated enterprise data analysis? No. Very much no. Does it also mean that your people are suddenly ready to embrace this new technology and leverage all of its benefits? Probably not. Why? Because an EMR, contrary to popular belief, is not a panacea for the personal accountability and data problems in healthcare:

• If you want to analyze any of the data from your EMR you still need to pull it into an enterprise data model with a solid master data foundation and structure to accommodate a lot more data than will just come from the system (how about materials management, imaging, research, quality, risk?)
  • And please don’t tell me your EMR is also your data warehouse because then you’re in much worse shape than I thought…
  • You’re not all of a sudden reporting real time. It will still take you way too long to produce those quality reports, service line dashboards, or <insert report name here>. Yes there is a real time feed available from the EMR back end database, but that doesn’t change the fact that there are still manual processes required for transforming some of this information, so a sound data quality and data governance strategy is critical BEFORE deploying such a huge, new system.

The list goes on. If you want to hear more, I’m armed to the teeth with examples of why an EMR implementation should be just that, a focused implementation. Yes it will require more resources, time and commitment, but don’t lose sight of the fact that there are plenty more things you needed to do with your data before the EMR came, and the same will be the case once your frenzied EMR-centric mentality is gone.

Personnel, personnel, everywhere, nor any data to drink.

IT’S UNFORTUNATE: Large amounts of money are spent on new hires, yet little is left for employee and data improvement

I recently had an Executive Director of a Cancer Institute tell me,

“At this time, we plan to use simple spreadsheets for our database.  We are committing more than $500,000 for investment in personnel to start our translational laboratory this year.  I hope  we can subsist with simple spreadsheet use for our pilot studies.”

This sentiment immediately followed a detailed discussion, one that I’m very familiar with, concerning disparate researchers’ databases and how organizations’ needs remain unsatisfied, suffering from lack of integrated data.

Just so we’re all on the same page, let me make sure I understand this situation correctly –

1. You are currently using “simple spreadsheets” to assist researchers with all things data. You’ve astutely noticed that these stale methods don’t meet your needs, and you agreed to a meeting with Edgewater because you’ve heard positive success stories from other cancer centers.
2. You just spent three quarters of a million dollars on fresh staff for a new translational lab.
3. You are now budget-constrained because of this arrangement and want these new hires to use “simple spreadsheets” to do their new job… the same ineffective and inefficient spreadsheets, of course, that caused the initial trouble.

Did I understand all that correctly? I didn’t grow up in the ’60s, so I’ll continue to pass on what he’s smoking.

So who wins with this strategy, you ask? No one!

We keep buying things thinking 'that'll look better' and it just doesn't

It’s unfortunate for the researchers because they continue to rely on an antiquated approach for data collection and analysis that will continue to plague this organization for years to come.  How many opportunities will be overlooked because a researcher becomes overwhelmed by his data?

It’s unfortunate for the organization because it’s nearly impossible to scale volumes (data aggregation, analysis, more clinical trials, more federal/state grant submissions, etc.) with such a fragmented approach. How much IP will walk out of the door for these organizations on those simple spreadsheets?

It’s unfortunate for the brand because it can’t market or advertise any advances, operationally or clinically, that will attract new patients.

It’s unfortunate for the patients because medicine as an industry collectively suffers when:

• Surgeons under the same roof don’t recognize and notify their counterpart researchers that they have perfect candidates for the clinical trials they’re unaware of.
• Executives continue to suffer budget declines from lower patient volumes and less additional revenue from industries partnering with cancer centers that have their act together.
• Researchers under a single roof don’t know what each other are doing.

As in the picture above, “more” doesn’t necessarily mean “better.” Ancillary personnel and sheets of data don’t necessarily equate to a better outcome. Why continue to add more, knowing that this won’t solve the problem? Why infect more new hires with the same sick system? Why addition instead of introspection?

So, just as I told him in my response, I look forward to hearing from you in about 12-18 months; that’s roughly the amount of time it took the last dozen clients to call Edgewater back to save them from themselves.

Why are YOU going to the OR Management Conference this year?

This will be my second time at to the annual OR Management conference. I enjoyed the conference last year, which highlighted subject like operational efficiencies, new modalities of treatment, Lean methodologies, materials standardization, etc. I’m sure this year will offer similar educational opportunities, but that’s not why I’m going.
After working in an operating room and three years of attending Operating Room-related conferences and consulting with clients in the healthcare industry, it has become clear to me that there is a gap between what OR Directors and Managers do on a daily basis and the expectations their administrators set for them. Let’s face it: OR Managers and Directors are typically hired for their clinical experience. The shame is that, despite their credentials, these people end up spending the majority of their time putting out fires, managing surgeon and anesthesiologist egos, and fighting political battles. Unfortunately, very little time is spent “actually managing the OR like a business.”
However, this laundry list of management disasters does not negate executives’ expectations of the new OR director, who often ask directors to:

• Lower variation of implant and material choices across service lines
• Improve first  case on-time starts
• Reduce SSI rates
• Increase block and overall room utilization
• Drop turnover time from 44 to 23 minutes

All of these demands have something in common – they require integrated data from multiple systems in the OR to analyze and address. However, when I talk to managers about their worries of integrating this data to efficiently address the executive demands, they are reluctant to change. The most common justification is, “Well, we already have a Corporate IS department,” or even “Well, we have [insert EMR vendor’s name here] tool for that.” This response makes me laugh (and cry) because it differentiates those who “get it” and those who don’t.
Every hospital is unique, every Operating Room with its own set of priorities, systems, processes, and people; there is currently no off-the-shelf or black-box solution to help an OR Manager actually manage an OR. Yes, there is a module for Quality somewhere over here, and maybe an app for Labor & Productivity over there, but there can be no standard comprehensive, scalable, extensible solution that accommodates the variety of clinical, financial, operational, research, market share, physician credentialing, materials management, and other disparate data sets of each hospital.

However, despite the strength of the solution, it is not a costly effort; the ROI is short-term and clear. There should be money in every budget to build these solutions, because they are built to help address immediate, short-term needs (such as better reporting for quality; analysis for standardizing implants in total joints) and long- term needs (such as multi-facility standardization, automated external and internal reporting of patient safety and quality measures, integrating health plan and other data for measuring true cost per case).
I’m going to the conference to see how many of the OR Managers embrace this approach, are eager to capitalize on the huge opportunities there are to save millions of dollars in the OR, and understand that Corporate IS departments don’t help the business users create solutions that can help you do this:

or this…?

Are you ready to embrace the opportunities your institution has starting with integrating your data? Will you join me at the OR Managers conference? I’d like to hear your unique needs and how we can collaborate and address them together.

Thoughts on 2011 AHA Health Forum Leadership Summit: Coach K’s Five Challenges

The opening keynote address by Tom Brokaw was a motivational, inspiring start to the AHA Leadership Summit. Coach Mike Krzyzewski (Coach K) reluctantly spoke after Mr. Brokaw, his long-time friend and admittedly, “a tough act to follow.” Coach K spoke about what good leadership is and how it relates to those of us in healthcare. One of the most impactful lessons his mother ever taught him was told as a simple metaphor: “On the bus you drive through life, be sure to only let good people on…and if you’re trying to get on another bus, make sure there are only good people on that bus too.” It’s pretty straight forward – recruiting and scouting is everything. Just kidding….as he was, but it means a lot. The way you lead is reflective of the type of company you keep, and the ways in which people feel about your company and leadership.

In addition, Coach K emphasized the importance of a cohesive, collaborative healthcare environment. He leveraged a story Tom Brokaw told. Tom mentioned how during the Nixon Watergate scandal, the political environment was so divided, that before a Republican and Democrat came on his news show one day, they called ahead and wanted to be sure each other was not in the Green Room at the same time. How were these political leaders supposed to achieve anything if they literally couldn’t even stand in the same room as one another?! Coach K spoke about his emphasis on team-building exercises because every year he had new players to incorporate into their offensive and defensive schemes. The challenges, though, were similar. Players would come from backgrounds in different systems with unique styles, and the coaching staff had to find the right ways to make the collective team mesh. More importantly, he had to help his team win. Most importantly, he had to turn boys into men and prepare them for challenges bigger than a basketball court.

The challenges he posed to the audience were these:

1. Communicate – “When you communicate, do you look your patient in the eye? Do you address them by their name and remember their kids sport? Their husbands name?”
2. Trust – “Are the principles and practices of your office/hospital/clinic trustworthy? Are you honest and straightforward with your patients about your level of care? Compared to others? Is there full transparency to all the things you do?”
3. Collective Responsibility – “When was the last time you/your people got hit? Something that knocked you back, knocked you down…and you really felt it? When something bad happens does everyone get together and help solve the problem? Or does a blame game start? You’re all in this together; you got into healthcare to help people. Make sure they know you’re a team.”
4. Care for One Another – “Anger is a good emotion if it destroys something bad. Cancer is bad, diabetes is bad, and Alzheimer’s is bad. You should be angry at these diseases and, at the same time, empathetic with those struggling to survive with them. Always put yourself in the patients’ shoes before saying or doing anything” – healthcare must become more patient-centric, or as one comprehensive cancer center has tagged it, “personalized medicine”.
5. Pride (in something bigger than yourself) – “You have to feel it (visualize it, hear it) in order to effectively address, resolve, and improve it.”

“You can want to win, but you must prepare to win”. Preparation starts with an understanding that healthcare has become a team sport –specialists and clinicians must leverage each other’s experiences and expertise to provide patients the best possible outcomes. And since this is my area of expertise – I can add, “it starts with sharing data!”

Will there be a greatest generation of healthcare?

I was fortunate enough to attend this year’s 2011 AHA Health Forum Leadership Summit in San Diego, CA and have a few thoughts I think are worth sharing. The keynote speaker lineup was unrivaled and from each came a call to action to the audience for one common thread – “find more opportunities to work together, than let excuses keep you divided.” Tom Brokaw, Coach Mike Krzyzewski (“Coach K”), Dr. Atul Gawande, Fareed Zakaria, and Amy Woodruff all graced the stage and had messages that seemingly united the crowd, if for just a short few days.
Tom Brokaw opened the conference with a simple thought: “When I wake up these days, I find myself asking, ‘Is this still the same America that was able to achieve so much coming out of World War II?’ From civil and women’s rights to mobilizing an entire country for not one but two world wars – I’m discouraged by the divide that seems to have permeated our society.” Mr. Brokaw wrote The Greatest Generation so his view may be slightly bias, but nonetheless, I couldn’t help but agree with him. It seems there are fewer opportunities for finding common ground. Too many people are so caught up in “sticking to their principles” that the benefits of compromise are often overlooked. It is no longer what is best for the country, rather what’s best for me or my party or my agenda or my industry…
Mr. Brokaw highlighted the opportunities for improving the healthcare industry starting with two fundamental principles: greater transparency and information sharing. He told a story of how he asked a room full of American company CEO’s one question that none of them knew the answer to, “how much did you spend on healthcare last year?” The industry must improve its ability to empower patients (consumers) with better access to cost information. In addition, the sharing of data across physician practices, acute care settings, and disparate business entities like health plans, physician groups, and hospital must enable a better coordination of care. Patients, especially the ones with chronic conditions, will never be able to properly manage their disease without these critical links. Unfortunately for those of us in the healthcare industry, we have an uphill climb.

Integrating Cancer Center Data: One easy place to start

"Where do I begin?"

In working with a number of cancer centers, we’ve recognized that they all struggle with one common problem when considering an enterprise data strategy or framework for enabling personalized medicine: “Where should we start?” While the question seems so basic, the answer eludes even the most well-intentioned and well-informed organizations. In beginning a project, a company must consider two successful approaches.

Two Successful Approaches:

①   Start with an Enterprise Data Strategy to understand what the governance and organizational roadmap should look like across care settings and, for large health systems, across business entities…

• Then – as part of the strategy, identify one area or proof of concept, to start your data integration. One client of ours said, “Find a target rich environment” to integrate a small subset of data and demonstrate the value proposition of your strategy. The particular client chose surgery and we built a robust Surgical Analytics solution.

②   Start with a proof of concept to demonstrate the value of integrating data. This will allow you to get buy in from other stakeholders in your organization and generate momentum for what is needed on a larger scale…

• Then – create and Enterprise Data Strategy that will bring similar value identified in the POC across the organization.

The approach you choose depends on the amount of buy-in there is within the organization among business, clinical, financial, and technical leaders. If there is hesitation or uncertainty as to the value of an enterprise data strategy or too many people are still saying, “We don’t really need one,” go with option #2 and show them they do.

Getting Started

Promoting collabertive research

One easy place to start for cancer centers to generate an easy win and clear value for the organization is integrating bio-specimen tissue repositories. Integrating the data from all the different bio-specimen banks that lie in disparate off-the-shelf software packages that come with the freezers the specimens are stored in is a clear and easy sell.

The primary objectives for integrating tissue repositories are as follows:

• To promote collaboration in research among scientific staff
• To attract new research opportunities with a quantified resource
• To provide accurate information for promoting external research opportunities
• To enhance standardization across repositories
• To enable the association of clinical data and specimens as an enterprise asset
  • Able to stratify specimens with clinical data
• To reduce risk for policy deviations for the use of bio-specimens

Healthcare’s Conundrum: (IN)Decision by Committee – Good at Making Friends, NOT at Making Progress

I should start by mentioning the fact that I clearly hit a nerve on my last blog post about the huge cost “Decision by Committee” adds to the healthcare system. People agree with me, yet are hesitant about being as straightforward as I was….so be it.

Having said that, I should be straightforward about my next point – “decision by committee” impedes progress. If you know Moore’s law, or have seen the new Best Buy commercial about the “outdated world” (which I must admit is funny) you know that technology advances very quickly. Not just in retail or gaming and entertainment, but in almost every industry. Therefore, healthcare executives are inherently doing themselves a disservice by delaying their technology upgrade and new purchasing decisions. This problem isn’t restricted to just hardware and software either, but integration technology (SQL Server), business rules engines, data warehousing, knowledge management sites (SharePoint), patient relationship management applications (Microsoft CRM), patient portals, etc. By the time an organization identifies the need for new technology they have a short window to capitalize on the benefits without sacrificing some of the downsides of waiting to implement. Whether the driver is to achieve a competitive advantage, meet the demands of an evolving market place, comply with regulations, or satisfy individual stakeholders, they all would benefit from a faster implementation schedule. So why does everything take so long?

Everyone knows time is money. The problem is no one is cognizant of the opportunity cost associated with delayed and prolonged decision making. They think the money clock starts ticking once the project starts. What an outdated way of managing! The clock starts ticking as soon as you’re organization has agreed that the need exists and you need to find someone or something to meet it! This isn’t rocket science people.

“Progress” in the context of this blog is when healthcare finally starts to achieve the efficiencies from utilizing IT that retail, banking, and even life sciences did 20 years ago. The main point we should all agree on: “healthcare should be run like a business” and the last two blogs I’ve written speak directly to this. If for some reason you think this is a bad idea because “it takes away from the focus on the patient” then stop reading because I know you don’t work in healthcare or understand where the inefficiencies in the system lie and we shouldn’t be talking anyway.

Unfortunately, efficient and appropriate decision making is an important organizational component that is not characteristic of large committees in healthcare organizations.  There is typically a concern that too much risk may be made that could compromise patient care or safety.  However the opportunity lost with indecision may be as much or more costly.