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Two Views of BI
Business intelligence can be described as a process that leads to better decisionmaking. In its original and ongoing mission, a business analyst selects and extracts
historical data from one or many databases. The analyst then structures and loads
the data into a single repository (a data mart or data warehouse). Analytical and
visual tools are then applied to perform trending and comparative studies that, sliced
in different ways, create reports to measure performance and uncover opportunities
for improvement.
In contemporary form, BI also takes an operational approach that gathers near realtime data to support ongoing processes. These include sales, marketing and
customer interactions. Operational BI is more process oriented than the data
warehouse model and is associated with key performance indicators, dashboards
and scorecards that support performance management.
In the clinical world, health care providers have tuned operational workflows to fit
processes from admission and treatment to checkout with a flexibility other industries
might envy. A visitor to an emergency room or someone admitted for an inpatient or
outpatient treatment might well regard the event as orderly and procedural.
Whether or not this appearance is true, the actual management and reconciliation of
data that flows through admissions, doctor notes, labs and pharmacies becomes a
huge challenge to implementing BI. And data complexity provides only a partial
explanation of why the industry is a relative late-comer to the BI strategies employed
in other economic sectors.
While current budgets are tight everywhere, the health care sector has traditionally
been an IT spending laggard. Without accounting for scale, a 2009 Gartner
Research note predicts that the financial services industry will spend more than six
dollars on IT for every equivalent dollar spent by health care this year. But according
to figures from HIMSS, the Healthcare Information and Management Systems
Society, this under spending may change. Spending, which now sits at
approximately 2 percent of total revenue, is expected to grow at a compounded rate
of 7.5 percent through 2014. A 2008 snapshot of health institutions conducted by
IDC subsidiary Health Industry Insights found that less than 20 percent had instituted
an enterprise data warehouse. The study also found that more than 30 percent were
planning to do so.
Setting Priorities
Despite the uneven spending on IT, health care as an industry aspires to the vision
of a digital hospital with consolidated electronic records, but this does not describe
the state of work under way. Its a step-wise approach to the vision. Many institutions
are still turning from paper to discrete software applications that might cover a single
workflow, such as processing new patient admissions or facilitating orders for lab
tests.
For CIOs, maintaining the vision of the digital enterprise requires tenacity. In 1999
when Indranil Ganguly arrived as CIO at CentraState Healthcare System, a 271-bed
2
acute care and outpatient facility in New Jersey, clinical data was being captured
electronically, but not in a way that supported decision-making. When I and a couple
of others joined the organization we saw technology that was simply as a surrogate
for paper. It was not adding value, and maybe was impeding value by making it more
onerous to retrieve information.
Some of CentraStates discrete applications offered light reporting and bits of clinical
and BI value, but at a very low level. What Ganguly chose was to rip and replace
isolated or weakly connected applications with a more unified platform from Siemens
Medical Solutions that helps integrate data from multiple operational processes.
CentraState is hardly alone in this regard: One of the most obvious trends in health
care information systems is that hospitals and integrated care networks are widely
replacing older applications and connections with newer platforms. An expectation is
that new technologies will also take over much of the data quality and integration
heavy lifting, in part to fuel BI reporting and performance management. At Legacy
Health, Gibson has torn out an expensive platform that was still under construction
and replaced it with software from Epic Systems Corp. The new rollout connects the
emergency department, critical care, physician office billing, hospital billing, hospital
and clinical operations across Legacys facilities.
From a financial perspective, as government and third-party payers look for ways to
control costs, its incumbent on hospitals to churn more detailed information, says
Marc Holland, a former IDC Health Insights analyst who now runs a practice called
System Research Services. Hospitals need to better understand their actual costs,
reduce the cost of providing care and concentrate on increasing market share in
services that are most profitable. In order to do that, he says, providers need more
than traditional diagnosis-related group, discharge summary and billing data. You
need information about the kind of care that was delivered to the patients throughout
the course of their stay. Hospitals know they need a lot more clinical data in digital
form than theyve traditionally had.
A Unified Transaction Record
The march toward clinical IT adoption and the BI functions it would enable long
predates the current federal government incentives to adopt electronic health
records. While many EHR programs today are executed solely to improve safety and
manage clinical processes, they also aggregate data and enable connections to
financial platforms.
The rise of BI and clinical intelligence, says Holland, is due in part to the fact that
many hospitals have several years of experience with full-blown EHR systems that
are yielding some of the missing pieces of the puzzle in terms of the kind of care
delivered, when it was delivered, who delivered it, how long the stay was and what
the outcome looked like.
The transactional focus of EHRs bears a canny resemblance to enterprise resource
planning software, which sprang up across all industries in the 1990s through post
Y2K as a means of centralizing transactional data. ERP evolved to support sales,
But Denver Health is also profiting from a Siemens standardization that extends
across clinical and financial applications. Seventy percent of our clinical systems
and probably 90 percent of our financial systems are now on Siemens, says Jeff
Pelot, chief technology officer at Denver Health. And Denver Health is upgrading to
the latest version of the Siemens Suite, which comes with built-in analytics and
workflow, which Pelot says will increase the ability to collect and leverage data.
Despite these plans, Denver Health must still turn to a variety of IT vendors to
support clinical operations, picture archiving, lab systems, cardiology and outpatient
pharmacy. Integration is accomplished with help from Siemens but mostly through
an internal interface engine that allows data to be written once and read in many
systems, including the data warehouse.
In the ERP world, platform vendors have grown more dominant and improved
product lines steadily over the years. They have also acknowledged the need for
specialized and heterogeneous technology infrastructures, a trend also proving true
in health care.
Under the very best of circumstances if you bought everything you could from the
smallest number of vendors you would still have a substantial variety of information
systems just because of the nature of health care, says Vi Shaffer, an analyst with
Gartner Research and 30-year veteran of the health care industry. Youre always
going to have interoperability and interface challenges; the standards bodies have
done yeoman service over the years to help that along but we still have a long way
ago.
The risk of non-standardization also exists where inaccurate sharing of information
might affect patient safety. An example arose years ago at Geisinger Health System
where, in a pilot program, order entry and pharmacy data were mismatched and
patients were sometimes ordered the wrong medications or doses. The error was
corrected four years ago but a BusinessWeek article recounted the episode as
recently as April under the gloomy title, The Dubious Promise of Digital Medicine,
and quoted James Walker, Geisingers chief health information officer, as saying that
providers are thinking, Look, lets slow down.
Walker now says his quote was taken out of context and that safety issues around
data quality are an ongoing priority in every aspect of hospital operations. Were
deadly in earnest about making electronic health records safer but there is no
question in my mind that the EHR has already made care safer than it was before.
In fact, he says, once you get used to having all that information in a form thats
usable, its scary to take care of patients without it.
Standards also change outside the four walls of databases and institutions. An issue
at Geisinger and other facilities is the transition to ICD-10, the latest global coding
standard for diagnoses and disease established by the World Health Organization.
ICD-9 does not translate to IDC-10, and we need to understand how were going to
make that work for billing, for our clinicians, for our data warehouse and other
systems with comparable data, Walker says.