Data Warehouse for Health

Case study of a DWH for health in french hospitals.

by Timothée CAPALDI
Table of Content

Table of Content 1

Introduction 2

Case Description 2

Is an hospital a business? 2

What is the EDS project about ? 2

What type of Data Warehouse is used and why? 3

How to access the data? 4

Can a patient deny access to his/her data? 4

Who has implemented the EDS Data Warehouse ? 4

What were the requirements for the implementation of the Data Warehouse? 5

Intranet or Internet? 7

What business decisions are made based on the Data Warehouse? 7

Data Science 7

What benefits did the Data Warehouse deliver to the company? (Explanation
and examples) 8

What were the problems encountered during the implementation? 9

Is the Data Warehouse bought or built? (Product vs custom built) 9

Conclusion 10

Recommendations 10

Sources & Literature 10

This paper is organized in questions and answers, this format provide a better
immersion in the case from the service perspective.

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Introduction
In this paper, I will study the case of a data warehouse for health (​EDS​)
implemented in french hospitals by APHP (​Assistance Publique des Hôpitaux de
Paris​).

First, I will give a case description including a reflection about business in the case of
an hospital as well as an explanation of what is the data warehousing project exactly
about and what is the goal of it. I will illustrate the type of data warehouse chosen in
the case and why the organisation selected this one. Then I will say who has
implemented the solution and how. I will pursue with the requirements for the case,
the economic decisions made on the Data Warehousing, examples of benefits
delivered by the data warehouse to the company, the problem encountered during
the implementation and why did the APHP build the data warehouse by themself.
Finally, I will give a conclusion, recommendations and a literature list to complete the
case.

Case Description
The APHP​ (​Assistance Publique des Hôpitaux de Paris​), is ​a french organisation
and ​the world biggest hospital group​ (39 hospitals, 100.000 employees and a
budget of 7 billions of euros per years). The case study is about a data warehousing
project recently implemented in their hospitals: ​the EDS​ (​Entrepôt de donnée de
santé​, literally “Data Warehouse for Health”)

Is an hospital a business?
Officially, ​an hospital is not a business​. Hospitals are not corporations because
they don’t serve a lucrative goal but focuses on the patient. But it almost follows the
business model, almost because on essential points (e.g. staff management), a lot of
reglementations are handicaps that would lead any corporation to bankruptcy.
Hopefully, these handicaps are compensated with subventions from french social
security.

Beside from that, ​I am going to consider the APHP as a business in this paper​ to
answer questions about this case that could also be applied to the case of a
traditional corporation.

What is the EDS project about ?

The EDS, is a data warehousing project for hospitals of the APHP to be able to save
administrative, social and medical data collected about patients during consultations.

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The goal of such a system is to contribute to researches ​like non interventional
data researches and feasibility study on clinical cases.

What type of Data Warehouse is used and why?

For their EDS project, the APHP uses the software I2B2 (Informatics for Integrating
Biology and the Bedside). Their architecture is illustrated on figure 1.

Figure 1. EDS architecture. Adapted and translated from Entrepôt de Données de

Santé​, ​in​ CME APHP​, B.R., B.S., D.C., T.L., Z.M., Retrieved 2015 from
http://cme.aphp.fr/​.

On the figure, you can see several components from a data mart (Orbis, PMSI,
PACs etc.) standardized and securized into the data warehouse. This data
warehouse is created in I2B2, a software often used for hospital data warehouses.

Two different kind of studies​ will be stocked in the data warehouse: the
“self-service”, the studies that are made inside the care team (​Monocentric​), and
“case-by-case”, the rest of the studies made by either the service, the pole, the
hospital, the research network or the APHP (​Multicentric​).

This solution is ​very simple because it only uses one software to manage all
data.

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How to access the data?
Any doctor who would like to use the data from the warehouse to conduct
researches needs to ​ask the CSE​ (​Comité Scientifique et Éthique,​ literally​ “​scientific
and ethical committee”).

If the CSE allows the doctor to access the data he/she needs for his/her study, ​the
doctor will be allocated a temporary or permanent access​ (depending on the
case of the research) and will have to ​follow a training to the software I2B2.

Can a patient deny access to his/her data?

As a code for ethic, the hospital have to ​inform the patient about the data
warehouse​ and the ​patient should be able to refuse the gathering of his/her
data.

In case you are a patient and you don’t want the hospital to collect your data to
conduct studies, you will have to ​fill in a form available online​ with your personal
information and indicate that you refuse data collection to serve studies. ​If you
don’t, you implicitly agree to data collection for study purpose.

Who has implemented the EDS Data Warehouse ?

To implement the data warehouse, the APHP needed ​their staff ​to collect the data,
their doctors ​to set up requirements and think of a structure and​ their IT
department together with experts in big data ​to review the requirements and
apply them.

The beginning of the process is done ​without the IT department and experts:​ the
staff ​collect all existing data in any format​ (paper files, excel etc.) and the doctors
set up requirements and design the tables based on these data and choose the
software​ (I2B2)​.​ finally, doctors meet the head of the hospital to​ validate the
requirements and design.

The rest of the implementation is done ​by the IT department with the help of the
experts:​ They ​review the design of the tables​ (structure and organisation),
physically implement it​ and ​define roles and responsibilities for maintenance.

in my opinion, ​it is clever not to ask directly to the IT department and experts to
make the requirements​ because those who will use the database are ​the doctors
so it is better that ​they design it from their point of view​.

in the next paragraph, I review the requirements given by the doctors to the IT
department.

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What were the requirements for the implementation of the Data
Warehouse?
3 aspect were taken into account in the requirements that the doctors did set
up​ for the implementation of the data warehouse: ​methodological, ethical,
practical.

Requirements ​are detailed in the following points: (traduced and adapted from the
APHP website)

I. Get all existing data in any format​ (locally collected data in Excel files) to
reuse it.

II. Make the data trackable​. The service should be able to find the primary
source of any data in the warehouse.
A. Provide a unique id to each patient (this id is called “patident”). This id
must be the same in any file of this patient including paper files and
imagery.
B. Any modification to any data needs annotation and documentation.
C. The warehouse needs a dashboard for management.

III. Follow ​standard steps in the data warehouse creation.

A. Design the warehouse​ in terms of (1) ​inputs​ and (2) ​table
organisation​ inside the data warehouse.
1. What ​inputs​ (variables, fields, columns)
a) Existing data ​must be analysed to understand​ what
items are going to be collected.
b) When done, ​items must be reviewed​ to make sure it is
useful. Criterias to keep items will be stocked in the
database as well and should provide a balance between
exhaustivity​ and the risk of ​missing information.
2. Table organisation​ (type & content)
a) use a ​unique key id.
b) use a​ codebook​ to indicate the details of every variables
(name, description, coding). coding must be verified.
c) use ​“brut” data before computing​ (weight and size
instead of body mass index, dates and instead of
durations).
d) make a ​difference between missing, n.a (not
applicable) and removed​ for unused fields.

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 e) use a ​1-n relational structure​ as follow:

B. Define the ergonomy of the input and functionality​. For example, in

a single base, associate the consultation and the operation.

IV. Use ​ONE specific software​ to enter data (no more excel !).

V. Validate any data that is entered​ during the conception of the warehouse to
correct any mistake before launching the final product.

VI. Never modify original data​ after validation and register any previous
modification.

VII. Archiving​ data is mandatory while entering and at the end of a study. It can
be done on local disk or via the internet.

VIII. Confidentiality ​requirements.

A. The entire ​warehouse must be conform to the french law about
data gathering​ and shouldn’t be contrary to individual rights of the
patient.
B. Any file must be documented and reported to the CNIL
(​Commission nationale de l'informatique et des libertés​, literally
national commision for IT and liberties).
C. Patient must be informed of data gathering​ and must be given an
access right.
D. Data must be encrypted​ and conform to cyber security criterias.

All the above points have to be complied while implementing the data warehouse
and processing to data gathering. It is important to ​have precise requirements​ on
the architecture like this so the implementation, utilisation and future iterations can
be easier. ​Norms and laws about DWH, privacy and confidentiality​ are also
major points for the head to validate the project.

Once the requirements are setted, the IT department and experts implement it. At
this point, they have to make a decision: Intranet or Internet?

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Intranet or Internet?
One major decision for the APHP during the implementation of the data warehouse
was to ​choose between an intranet and an internet hosted service.

Let’s sum up the advantages and drawbacks with an intranet solution.

We saw earlier in the section about what type of data warehouse is used that ​the
APHP did choose to host the database on the intranet of the hospital. What are
the advantages and drawbacks of that?

Advantages:

● It is easier to link the NIP (Permanent Identification Number) of a patient to

elements of his medical files.
● It is allowed to gather name and surnames
● It is less constrained by the CNIL (national commision for IT and liberties)
● It is possible to choose the softwares to use
● The protection of information is directly managed by the institution

Drawbacks:

● Not accessible from the outside (if government or another institution needs to
analyse the data)
● The data warehouse is totally dependant of the hospital IT department for:
○ the implementation
○ the maintenance
○ the choices (software)
○ the server situation

Another possibility was to host the database on an internet server​, this would
have make it ​more accessible​ and ​autonomous​ but it was also ​more expensive
and it needed ​more administrative procedures​. Furthermore, it is ​impossible to
gather names and surnames​ on an internet database for confidentiality issues.

This is the reasons why ​the data warehouse is hosted on the hospital intranet.

What business decisions are made based on the Data

Warehouse?
Data Science
Data Science is ​the art of computing data and using it to predict things.​ It is one
of the goal of implementing a data warehouse in a business (in this case the
hospital). Data Science can help business decision making.

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Thanks to a data warehouse, data scientists ​can prevent financial expenses and
help decision making.​ For example, they can ​quickly find out which patient is
the most in need of a treatment​ depending on his/her sickness and the ​decision
to treat the patient or not can be made accordingly.

Furthermore, the data can be used to ​detect a sickness like a tumor from a
radiography using image processing techniques​ and to ​predict how this
sickness can grow​ regarding the case of other patients. The hospital can then
predict the budget and the time that is going to be needed to take care of that
patient​ regarding similar cases.

Finally, statistics about the hospital in general like the ​number of patient treated​ or
the ​amount of medicine given​ and such can easily be calculated and kept in track.

Those are business decisions that become easier to make thanks to the
implementation of a data warehouse.

In next paragraph, I talk about the benefits of the project for the doctors, the patients
and the hospital.

What benefits did the Data Warehouse deliver to the company?

(Explanation and examples)
Everytime a patient enter in an hospital of the APHP for whatever sickness or injury,
his or her personal information as well as anything about his/her stay in the hospital
will be entered in the Data Warehouse. These data are used for business,
administrative and legal purpose but also for the research !

Thanks to this Data Warehouse, ​any doctor who would like to conduct a
research can easily acces every cases of patients​ who suffered from one
particular sickness and ​share​ it with another doctor that is working on the same
thing.

These data can also be ​useful for a patient that would like to go into legal
procedure​ because he/she is not satisfied by the services he/she received there. If
every data were correctly collected, every information about operations should be
there, and can be used as evidences in a tribunal in such a case.

In terms of business,​ it’s always better to be able to show and prove everything
that happened inside your team for legal purpose.

Beside from that aspect, I think data warehousing is a must have in any company or
organisation nowadays because it is ​way easier and faster to manage data​ in a
well implemented data warehouse than in any old school paper file database (edit: a
lot of hospital still uses paper files in addition to an IT system because it is easier

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hand in to the patient). ​In an hospital, time is crucial​ when it comes to a medical
operation or a transfer to a specialized place. ​A Data Warehouse to share data
about a patient between services or hospitals could save lives.

What were the problems encountered during the

implementation?
During the implementation of such a thing as a data warehouse, there is always
problems. Here are those the APHP encountered.

Because ​the staff​ of the hospital is not expert in data warehousing or even in IT in
general, every member ​had to be teached how to use the softwares properly​.

Rules also had to be established​ to clarify who can access to what inside the data
warehouse.

Permissions​ from CNIL (Commission na​tionale de l'informatique et des libertés​,

literally national commision for IT and liberties) had to be obtain to proceed to any
type of change in their IT system.

Last but not least, ​predicting the infrastructure of tomorrow​ was also an issue
because implementing a data warehousing is a colossal investment that must be a
long term one.

Is the Data Warehouse bought or built? (Product vs custom

built)
The ​tables and architecture of the database is designed by the doctors​, the
data warehouse is ​built by the hospital IT department with the help of data
expert​ and data gathering is done by the regular staff. ​The Software used to
manage the data warehouse is bought: it is I2B2​, a software specialized in health
data warehousing.

In this case, because the data warehouse contains ​sensitive data, privacy is
essential.​ This is the first reason why the APHP had to build the database by
themself. They are not allowed to share any of the information gathered in that
database.

Second reason is for ​the maintenance​, IT department knows everything about the
structure of the data in the data warehouse because they did enter it, it is easy for
them to maintain and regulate the data in case of problems.

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Conclusion
This project, as well as any data warehousing project, is a long term investment with
colossal financial issues. For this reason, every step had to be taken very seriously.

To sum up:

● The ​data warehouse for health was built by the IT department of the
hospitals together with big data expert​.

● The ​data inside the warehouse are gathered by the staff​.

● The ​requirements are set by the doctors who are going to conduct
researches thanks to these data​.

● Data Scientist can also use these data to help business decision
making.

I think this way of implementing the data warehouse is interesting because in this
case, the users (doctors) are directly participating to the design of the database. Of
course this needs doctors that are also qualified in basic data warehousing but it
permits a result focused on their needs.

Recommendations
If I had to make recommendations for the case, I would first say that they have to ​be
very careful with the training of the staff​ because they are those who will enter
data from patient in the database during a consultation. I would even recommend to
assign​ ​an IT team to validate any new input​ before adding it to the final database.

Then, I would recommend to make a precise ​documentation of the tables and

structure​ of the database for the doctors to find data easily.

Finally, I would invite the head of the hospital to ​make sure the data warehouse is
conform to norms and laws from the CNIL​ to avoid any type of legal issue.

Sources & Literature

L'entrepôt de donnée de santé. (n.d). Retrived from ​https://recherche.aphp.fr/eds/

Mise en place d’un entrepôt de données de santé et de son cadre d'utilisation.

(2016, september 15). Retrived from ​https://aphp.fr/

Entrepôt de Données de Santé​, ​in​ CME APHP​, B.R., B.S., D.C., T.L., Z.M.,
Retrieved 2015 from ​http://cme.aphp.fr/

Hirsch, M. (2017). ​L'hôpital à coeur ouvert. ​Retrieved from ​https://livre.fnac.com/

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Paulraj Ponniah (2010). ​Data Warehousing Fundamentals. ​Hoboken, N.J.: John
Wiley & Sons, Inc.

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