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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!

August 2010 Archives

Consider three different scenarios that place healthcare patient safety at risk. The first is an individual hazard, the second human behavior, and the third a system issue in the broad sense of "system" as distinct from information technology (IT).

The first consists in placing concentrated potassium alongside diluted solutions of potassium based electrolytes. Now you need to know that intravenous administration of the former (concentrated potassium) results in stopping the heart almost instantaneously. In one tragic case, for example, an individual provider mistakenly selected a vial of potassium chloride instead of furosemide, both of which were kept on nearby shelves just above the floor. A mental slip-erroneous association of potassium on the label with the potassium-excreting diuretic-likely resulted in the failure to recognize the error until she went back to the pharmacy to document removal of the drug.[1] By then it was too late.  

Second, a pharmacist supervising a technician, working under stress and tight time deadlines due to short staffing, does not notice that the sodium chloride in a chemotherapy solution is not .9% as it should be but is over 23%. After being administered, the patient, a child, experiences a sever headache and thirst, lapses into a coma, and dies. This results in legislation in the state of Ohio called Emily's Law. The supervisor loses his license and is reportedly sentenced to six months in jail.[2]

Finally, in a patient quality assurance session, the psychiatric residents on call at a major  urban teaching hospital dedicated to community service express concern that patients are being forwarded to the psychiatric ward without proper medical (physical) screening. People with psychiatric symptoms can be sick too with life-threatening physical disorders. In most cases, it was 3 AM and the attending physician was either not responsive or dismissive of the issue. In one instance, the patient had a heart rate of 25 (where 80+ would be expected) and a Code had to be declared. The nurses on the psychiatric unit were not allowed to push a mainline insertion into the artery to administer the atropine and the harried resident had to perform the procedure himself. Fortunately, this individual knew what he way doing and likely saved a life. In another case, the patient was delirious and routine neurological exam - made up on the psychiatric unit, not in the emergency room where it ought to have been done - resulted in his being rushed into the operating room to save his life.

In all three cases, training is more than adequate. The delivery of additional training would not have made a difference. The individual knew concentrated potassium was toxic but grabbed the wrong container, the pharmacist knew the proper mixture, and the emergency room knew how to conduct basic physical(neurological)  exams for medical well being. What then is the recommendation?

One timely suggestion is to manage quality and extreme complexity by means of check lists. A checklist of high alert chemicals can be assembled and referenced. Wherever a patient is being delivered a life-saving therapy, sign off on a checklist of steps in preparing the medication can [should] be mandatory. The review of physical status of patients in the emergency room is perhaps the easiest of all to be accommodated, since vital signs and status are readily definable. Note that such an approach should contain a "safe harbor" for the acknowledgment of human and system errors as is routinely performed in the case of failures of airplane safety, including crashes. Otherwise, people will be people are try to hide the problem, making a recurrence  inevitable.

The connection with healthcare information technology (HIT) is now at hand. IT professionals have always been friends of check lists. Computer systems are notoriously complex and often are far from intuitive. Hence, the importance of asking the right questions at the right time in the process of trouble shooting the IT system. Healthcare professionals are also longtime friends of checklists for similar reasons, both by training and experience. Sometimes symptoms loudly proclaim what they are; but often they can be misleading or anomalous. The differential diagnosis separates the amateurs from the veterans. Finally, we arrive at a wide area of agreement between these two professions, eager as they are to find some common ground.

Naturally, a three ring binder on a shelf with hard copy is always a handy backup; however, the computer is a ready made medium for delivering advice, including top ten things to watch in the form of a checklist, in real time to a stressed provider. In this case of emergency room and clinics, the hospital information system (HIS) is the choice platform to install, update, and maintain the checklist electronically. However, this means that the performance of the system needs to be consistent with delivery of the information in real time or near real time mode. It also means that the provider should be trained in the expert fast path to the information and need to hunt and peck through too many screens. The latter, of course, would be equivalent to not having a functioning list at all.

And this is where a dose of training in information technology will make a difference. The prognosis is especially favorable if the staff already have a friendly - or at least accepting - relationship with the HIS. It reduces paper work, improves workflow, and allows information sharing to coordinate care of patients.

This is also a rich area for further development and growth as system provide support to the physician in making sure all of the options have been checked. The system does not replace the doctor, but acts like a co-pilot or navigator to perform computationally intense tasks that would otherwise take too much time in situations of high stress and time pressure. Obviously issues of high performance response on the part of the IT system and usability (from the perspective of the professionals staff) loom large here. Look forward to further discussion on these points. Meanwhile, we now add another item to add to the vendor selection checklist in choosing a HIS: must be able to provide templates (and where applicable, content) for clinical checklists by subject matter area.

It should be noted that "the checklist manifesto" is the recommendation in a book of the same title by the celebrity physician, Atul Gawande, MD, who is also the author of an engaging column in the New Yorker on all manner of things medical and a celebrity since being quoted by President Obama in the healthcare debate. However, make no mistake. The checklist is not a silver bullet. By all means, marshal checklists and use them to advantage. Still, there are some scenarios where long training, experience, a steady hand, and concentration are indispensable. In flight school, take off and landing checklists are essential. This is the normal checklist. Non-normal checklists are also available on how to restart your engines from 30,000 feet. But a double bird strike on take-off at 5000 feet, disabling both engines, is not on anyone's list. You cannot even get the binder down off the shelf in the amount of available time, the latter generally being the critical variable in short supply. Then there is no substitute for experience, leavened with a certain grace.  But for the rest of us humans, and in the meantime, assemble, update, and use your checklists.

[1] "Potassium may no longer be stocked on patient care units, but serious threats still exist"  Oct 4 2007, http://www.ismp.org/newsletters/acutecare/articles/20071004.asp

[2] "An Injustice has been done," http://www.ismp.org/pressroom/injustice-jailtime-for-pharmacist.asp

Posted August 16, 2010 1:08 PM
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The cruel economy strikes again, and Mark Hurd is out as CEO at Hewlett-Packard Co. (H-P). First lesson learned here? Always be sure that your expense reports are accurate. If the participant in the event was "Jodie Fisher," then the documentation should say "Jodie Fisher". And, of course, while $20K - the alleged amount of over payment for marketing services reportedly not performed - is a tad north of dinner for 25 people at Charlie Trotter's (Chicago), we are not talking Enron (fortunately).  H-P said its investigation showed that Mr. Hurd did not violate H-P's sexual harassment policy, but other anomalies were uncovered.[1] There is no excuse for it, nor will any be suggested here. Zero tolerance strikes again - as well it should. And yet ...


Lesson number two, and this is a tough one. As Presidential candidate Jimmie Carter said in a notorious interview with Playboy magazine (in 1975), "In my heart I have lusted after woman." Much as the tabloids might miss the details of a juicy sexual adventure, this is not one. If this is not the case of a sexual phantasy gone astray, then I would not know one. Make no mistake. Mark Hurd is no Bill Clinton, who after all got to keep his job (along a strict party line vote). This is a severe penalty to pay for the "crime" of having a sexual phantasy. The cynic in me momentarily says Mr. Hurd ought to have been fired for failing to score, but that is an idea for which I apologize in advance to him, knowing that he is family man. Leave it to a numbers guy to try to impress a girl with ... well, numbers. No doubt he will schedule some time off to repair the damage done, and that is as it should be.


The third lesson? Life imitates art? Not quite. Life imitates Reality TV. And this is the sad part. Not to dump on the would be  femme fatal in this case, who, after all, was literally a Hollywood star and a contestant in a Reality TV show, she anticipated a settlement and reportedly has one. Not having a single fact in the matter, I infer that this is the governance paradigm in reality TV. Write a letter; get even more publicity (and maybe a settlement or at least another TV show); no harm done. Not quite. Now she says she's sorry that Mr. Hurd lost his job because he turned over her letter alleging sexual harassment to the H-P Board. I believe it. Rumors that she has reportedly invited him to appear with her on the next episode of The Apprentice have been debunked. While this has rich comic possibilities, I fear that I have crossed the line between reality and phantasy (again), just like this entire episode.


And that is the final lesson here. Strict corporate governance is appropriate. Corporate governance is different than The Lives of the Rich and Famous. The pendulum swings back-and-forth between wild parties and zero tolerance. Mr. Hurd's mistake was momentarily to confuse the non-reality of Reality TV with trust and integrity between human beings. Yet he ought to have known that, in many contexts, a mere conversation about sex (or anything remotely sexual) is a method of gaining power and maximizing revenue (through a settlement), especially among those who traditionally have lacked power. Poor judgment in choosing friends? You bet! The unintended result? Corporate America has lost a powerful and articulate leader, albeit an imperfect one, at a time when leadership is in short supply. We eagerly await his reflections (next book?) on life in the corporate jungle, business leadership, and the cruel economy; and if Mr. Hurd requires an editor or a foil for his ideas, then I hope he will reach out. He has a listening here.

[1] WSJ.com: August 8, 2010, "Mark Hurd Failed to Follow HP Code," BEN WORTHEN and JOANN S. LUBLIN, http://online.wsj.com/article/SB10001424052748704268004575417800832885086.html?mod=WSJ_article_MoreIn_Business

Posted August 9, 2010 9:54 AM
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What happens when an irresistible force meets an immovable object? We are about to find out. The irresistible force of BI, eDiscovery, compliance, fraud detection, governance, risk management, and other analytic and regulatory mandates is heading straight toward the immovable rock of year-to-year 10% reductions in information technology budgets.


The convergence of the markets for structured and unstructured data has been heralded many times, but maybe the time has come. We think that the new generation of solutions with increasing overlap of structured and unstructured data and multi-functionality will emerge and that BMMsoft EDMT® Server is the pioneer in that space. Looking into the crystal ball, what will happen is that an increasing overlap already underway will disrupt incumbents across these diverse markets.

The world wide BI Market as defined by Gartner is sized at $8.8B.[1] Realistically that includes a lot of Business Objects (SAP), SAS applications, and IBM solutions so the database part of that is probably closer to $6 billion.[2] The document management software market is estimated at nearly $3 billion.[3] While email archiving is relatively new and growing rapidly due to near federal regulations, it has now reached the $1 billion "take off" point. In short, at nearly $10 billion total, a product that addressed requirements across all three of these markets with a reasonable prospect of response from even one third of the enterprises, would have an outside boundary of over $3 billion. This is a substantial market under any interpretation.


In the meantime, the exiting markets for these three classes of products is fragmented into silos of the traditional data warehousing vendors, email archiving, and document management, the latter sometimes including compliance and governance software. The first are well known in the market - extending from such stalwarts as HP, IBM, Oracle, Microsoft, SAP, to data warehousing appliances and column-oriented databases - and will not be repeated here (though one new developments will be noted below). Document management systems include IBM FileNet Business Process Manager (www.ibm.com), EMC Documentum (www.emc.com), OpenText LiveLink ECM (www.opentext.com), Autonomy Cardiff Liquid Office (www.cardiff.com). Strictly speaking, risk management is considered a separate market from document management. Risk management and compliance offerings include Aventis (www.aventis.com), BWise (www.bWise.com), Cura (www.curasoftware.com), Protiviti (www.protiviti.com), Compliance 360 (www.compliance360.com) and IBM, which has at least two offerings one based on Lotus Notes and one based on FileNet. This list is partial and could easily be expanded with many best of breed offerings. The result? Fragmentation. Diversity, though not in a positive sense. Many offerings instead of a comprehensive approach to unified access and unified analysis.


Five years from now data will be as heterogeneous as ever and the uses of data even more so, but individual products - single instance products, not solutions - will characterize a transformed market for database management that traverses the boundaries between email archiving, document management, and data warehousing with agility that is only dreamt about in today's world. Video clips are now common on social networking sites such as Facebook and YouTube. Corporate sponsorship of such opportunities for viral marketing is becoming more common. The requirement to track and manage product brands and images will necessitate the archiving of such material, so multi-media (image/video/audio) are being added to the mix.


This future is being driven and realized by the imperative for business transparency, risk management and compliance, and growing regulatory requirements layered on top of existing business intelligence and document management requirements. Still, document management is distinct from workflow. If an enterprise needs workflow, then it will continue to require a special purpose document management system. Workflow was invented by FileNet in 1985, acquired by IBM in 2006, and continues to lead the pack where detailed step-by-step process engineering is required. Elaborate rules-engines for enterprise decision management are different than compliance. If an enterprise requires a rule-engine for compliance and governance, then it will need a special purpose compliance, risk management, and governance system. Such solutions would be over-kill for those enterprises that require email archiving for eDiscovery, document management for first order compliance, and cross references to transactional data in the data warehouse. While the future is uncertain, one of the vendors to watch is BMMsoft.


Innovation Happens

BMMsoft has put together a product delivering functionality across these three previously unrelated silos - data warehousing, eDiscovery (e-mail), and document management - and able to be purchased as a EDMT®Server - a single part number from BMMsoft (EDMT stands for "E-Mail, Documents, Media, Transactions"). The database "under the hood" is Sybase IQ, a column-oriented data store with a proven track record and several large objectively audited benchmarks. The latest of these weighs in at 1000 terabytes - a petabyte - and was audited by Francois Raab, the same professional who audits the TPC.org benchmarks.[4]  The business need is real and based on customer acceptance. So is the product.


The three keys to connect and make intelligible the data from the three different sources are:


1) extreme scalability to handle the data volumes - this is where a column-oriented database would come in handy since the storage compaction is intrinsic and prior to the additional compression that could be applied;

2) parallel, real-time high performance ETL functionality to load all the data; and finally

3) search capabilities that enable high performance inquiries against the data.

Such unified access to diverse data types, intelligently connected by metadata, is also sometimes described as a "data mashup."


A part of the challenge that a start up - and up start - such as BMMsoft will face is building credibility, which BMMsoft has already solved with numerous client installations in production and success stories. In the case of BMMsoft EDMT® Server there is another consideration:  metadata is an underestimated and underdeveloped opportunity. Innovations in metadata that make possible many applications that require cross referencing emails, documents, and the transactional data. For example, fraud detection, threat identification, enhanced customer relations - all require navigating across the different data types. Metadata makes that possible. That is not an easy problem to solve; and BMMsoft has demonstrated significant progress with it. Second, the column-oriented database is intrinsically skinny in terms of data storage in comparison with the standard relational database, which continues to be challenged by database obesity. As data warehouses scale up, the cost of storage technology becomes a disproportionably large part of the price of the entire system. Note that for the column-oriented approach proportional cost savings come into view and are realized. Third, this also has significant performance implications, since if there is less data - in terms of volume points - to manage, then it is faster to do so. So when all the reasons are considered, the claims are quite modest, or at least in line with common sense. The wonder is that no one thought of it sooner.


When you think about it for a minute, there is every reason that an underlying database should be capable of storing a variety of different data types and doing so intelligently. The latter intelligence is the "secret sauce" that differentiates BMMsoft. The relationships between the different types of data are built as the data is being loaded by BMMsoft using multiple software technology patents.  The column-orientation of the underlying data store - Sybase IQ - intrinsically condenses the amount of space required to persist the information, yielding up to an order of magnitude - more typically a factor of two or three - in storage savings, even prior to the application of formal compression algorithms. This fights database obesity across all segments - email, document, media, transactional (structured) data warehousing information. This means that the application that lives off of the underlying data is able to take advantage of performance improvements since less data is being stored and more being fetched with every data retrieval. For those enterprises with a commitment to installed Oracle or MySQL infrastructure, BMMsoft provides investment protection. The EDMT® Server runs also on Oracle, Netezza and MySQL and can be easily ported to any other relational Database. 


Thus, BMMsoft is a triple threat and is able to function as a standalone product addressing data warehousing, email archiving, and document management requirements as separate silos. But just as importantly, for those enterprises that need or want to compete with advanced applications in fraud detection, security threat assessment, customer data mining beyond structured data, BMMsoft offers the infrastructure and application to do so. For example, the ability to perform cross-analysis between securities traded on the stock market and those companies named in email and voice mail (remember multimedia handling) will immediately provide a short list for follow up detection on on-going insider trading or other fraudulent scheme. While hindsight is 20-20, a similar method of identifying emerging patterns through cross-analysis would have been be useful in surfacing the 8 billion dollar Societe General fraud, Madoff's nonexistent options plays at the basis of the pyramid, the Georgia Tech shooter, and relevant chatter that shows up prior to terrorist attacks. Going forward, this technology is distinct in that it can be deployed on a small, medium, or large scale to highlight emerging hot spots that require attention.


One may object - but won't the competition be able to reverse engineer the functionality and provide something similar using different methods? Of course, eventually every innovation will be competitively attacked by some more-or-less effective "work around." Read the prospectus - new start ups and existing software laboratories at HP, IBM, etc. will eventually produce innovations that challenge the contender. However, that could require three to five years. Then there is the matter of bringing it to market. IBM provides an example, based on publicly available news reports. IBM went out and purchased FileNet for about $5 billion dollars. FileNet is a great company, which virtually invented workflow, and if one requires advanced workflow capabilities, it is hands down a good choice. However, it does not do data warehousing or email archiving. As a subsidiary of IBM which delivers substantial revenue to the "mother ship," the executives in charge will set a high bar on any IBM innovations which combine email archiving and structured data warehousing with document management. In short, IBM is faced with the classic innovator's dilemma.[5] The price points that interest it - both internally and externally - are further up on the curve than the deals that BMMsoft will be able to complete. Given that BMMsoft has established presence in the market, it has a good chance of marching up market, displacing the installed, legacy solutions as it goes. This happened before in the client server revolution when IBM mainframe deals at the several million dollar price point were undercut by a copy of PowerBuilder and a copy of Sybase, albeit a different version of the database. Given that BMMsoft has a head-start, it is exploiting first mover advantages and building an installed base that will be challenged only with great difficulty. The relevance of such technology in the context of healthcare information technology (HIT) will be explored in a pending post. Please stand by for update - and keep in touch!

[2] For an alternative point of view see an IDC forecast (published 2007) that pegs the Data Warehouse management/platforms market as approx $8.97B in 2010


[3] Cited in "Document Management Systems Market: 2007 - 2010,":  http://www.researchandmarkets.com/research/c3917a/document_management


[4] http://www.sybase.com/guinness.

[5] Clayton Christensen, The Innovator's Dilemma. Cambridge, MA: Harvard Business School Press, 1998.

Posted August 9, 2010 8:31 AM
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