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Lou Agosta

Greetings and welcome to my blog focusing on reengineering healthcare using information technology. The commitment is to provide an engaging mixture of brainstorming, blue sky speculation and business intelligence vision with real world experiences – including those reported by you, the reader-participant – about what works and what doesn't in using healthcare information technology (HIT) to optimize consumer, provider and payer processes in healthcare. Keeping in mind that sometimes a scalpel, not a hammer, is the tool of choice, the approach is to be a stand for new possibilities in the face of entrenched mediocrity, to do so without tilting windmills and to follow the line of least resistance to getting the job done – a healthcare system that works for us all. So let me invite you to HIT me with your best shot at LAgosta@acm.org.

About the author >

Lou Agosta is an independent industry analyst, specializing in data warehousing, data mining and data quality. A former industry analyst at Giga Information Group, Agosta has published extensively on industry trends in data warehousing, business and information technology. He is currently focusing on the challenge of transforming America’s healthcare system using information technology (HIT). He can be reached at LAgosta@acm.org.

Editor's Note: More articles, resources, and events are available in Lou's BeyeNETWORK Expert Channel. Be sure to visit today!

In the healthcare IT (HIT) market, 'meaningful use' is the term of art used by the HIT Policy Committee (of the federal government) to qualify doctors and hospitals for reimbursement under the HITECH portion of the American Recovery and Reinvestment Act (ARRA). While the definition of 'meaningful use' is a work in progress, the broad outlines are starting to emerge. While a few grants have been 'let', so far dollars have been as scarce as cats in the swimming pool. Things are expected to pick up as the definition is clarified and actually improving the efficiencies of the healthcare system become an even more urgent priority. It is relatively safe to say:

  • Meaningful use is a data integration challenge. Clinical data such as hypertension, diabetes, smoking cessation, recommended tests (mammography, coloectal screening, and so on) have to be cross-referenced with demographics, eligibility for insurance, electronic healthcare records (EHR) in order to compare the effectiveness of treatments and procedures.
  • Comparative effectiveness research (CER) is a data integration challenge. This takes the 'meaningful use' challenge up a level. In order to assess the effectiveness of procedures, treatments, tests, the program has to access both the outcome of the procedure (did it work?) as well as financial data about its cost(s). Cost drivers include the time and effort of healthcare providers, the price of powerful drug therapies (an ongoing area of innovation), and what the payers agree to reimburse. This in turn results in the proposal to provide financial incentives to healthcare providers for improving quality ('performance').
  • Pay for performance is a data integration challenge. Like CER, this takes 'meaningful' use to the next level - providing a structure and incentives in terms of payments to healthcare providers (hospitals and doctors) for 'hitting their numbers'. The definition and production of those numbers is and promises to continue to be obvious in some cases and controversial in others, especially new and emerging treatments and technologies. However, in almost every case, clinical outcomes have to be lined up at a low level of granularity with what the cost is determined to be.

Of course, the healthcare is not a closed system or a completely rationalized one. Note that I say 'rationalized', not 'nationalized' (the latter is a story for another post). Medicare and Medicare payments continue to be the 2-ton elephant; and if Medicare does not pay, then how can a treatment be assessed as 'effective' or impacting quality? Obviously, there is a defined process for including a procedure or drug on the list of payment eligibility, including an act of Congress (I am not making this up), so there are many issues. For example, coordination of care is neglected and under-reimbursed (if paid at all) - where doctors are reimbursed to work together to care for complex illnesses of aging or life-style (not the same thing) such as diabetes, congestive heart failure, and kidney failure. Most of these disease entities require data integration of a life-time of healthcare treatments and transactions - like a 360% view of the client in customer relationship management (CRM).

Thus, as in most areas of the economy and across multiple vertical markets, data integration vendors who are engaging healthcare clients and applications are trying to hit a moving target. IT systems and infrastructure continue to develop in good times and in less good times. The standard relational databases are clean and effective data sources for the storage and manipulation of business and financial data in payment and run-your-healthcare-operation. But on the clinical side, heterogeneous data is ever more heterogeneous and even more inaccessible in proprietary systems such as Cerner, Eclipsys, GE Centricity, McKesson, and a whole host of other software providers. Even MedSphere which boasts about being 'open source' operates with the Mumps data store, not the target for development of new features and functions across vertical industries. I am not saying that Mumps is not 'open', but it does put the definition in context. Naturally, all data is accessible by definition in some form if you need it badly enough; but it might be a relatively inefficient dump to a batch file and clumsy handoff between heterogeneous systems, absent additional automation..

In data integration, connectors and adapters (plug-and-play type components to enable grabbing and transforming data sources into target patterns) are on the critical path to success. As in many markets, significant consolidation has occurred among data integration vendors as they have marched towards building platforms that combine data profiling, data quality, with data transformation and integration. Informatica is still touting its cherished independence as the proper database-neutral role to integrate all comers after Ascential with its famous DataStage technology joined forces with IBM in 2005 to provide the foundation of what is now IBM's InfoSphere data warehousing platform. Oracle has its own suite of tools, which continue to be a good choice for Oracle customers, including those considering Exadata; but Oracle has been slow to break out of the Oracle-to-Oracle niche (albeit a very large 'niche').

Pervasive software is a perhaps lesser known firm with offerings in data integration, service oriented architecture (SOA), and application development. Pervasive Software has contributed steadily to the development of innovative data integration technology for some twelve years, much of that as a publicly traded and scrutinized entity. Pervasive plays across multiple vertical markets from finance to retail, from manufacturing to insurance, from telecommunications to healthcare. The latter (healthcare) has been the target of this discussion. In 2003, Pervasive Software took a lesson from the play book of such Big Guys as HP, IBM, and Oracle - namely, innovation can sometimes be bought in the market easier than it can be developed in-house - and it bought some. Pervasive acquired Data Junction Corporation, makers of the Data Junction ETL (extract, transform, load) technology. This suite of data and application integration tools was rebranded and brought forward with enhancements and now known as Pervasive Data Integrator. No doubt "geographic determinism" played a role in the acquisition - both firms were located in Austin, TX. Pervasive continues to develop and market its high performance, flagship Btrieve database, PSQL This is more than passing interest from a technology perspective, since another B-tree database, Mumps, is quite common in the healthcare IT applications and implementations. Whether this will give Pervasive additional access is an open question, but it will surely give them additional insight into the technical dynamics and challenges of data integration and downstream applications such as business intelligence, pay-for-performance, and comparative effectiveness research, all of which are critical path in healthcare reform. I examined the technology at the time, and Data Junction brought to the market adapters for many relatively obscure data sources in small niches at a reasonable price point as well as all the standard relational databases and corporate data sources. Fast forward some six years, and Pervasive has built on the franchise, earning a spot on the short list of enterprises confronting information reconciliation, consolidation, and rationalization challenges. [This just in...update (12/16/2009): The Pervasive database team noted that 'Btrieve' is a registered trademark for Pervasive and actually based on B-tree technology. So 'Btrieve' would only refer to the Pervasive product whereas MUMPS is a 'B-tree' (rather than 'Btrieve') implemented database. Good catch! ]


Posted December 7, 2009 10:54 AM
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