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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 Americas 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!

Recently in data integration Category

Amid its 39th quarter of consecutive profitability, Pervasive has launched a new SaaS version of its flagship Data Integrator (DI) product called DI "Cloud Edition". In short, as part of a process described by CTO Mike Hoskins as "innovating below the water line," the Pervasive software development team has service-enabled the platform for SOA. This enables the DI product to bring its extensive connectivity to the cloud, either on the Pervasive DataCloud onAmazon's EC2, or on any cloud.

 

At the same time the architecture was undergoing a major upgrade, innovation was also occurring above the waterline. Significant functionality was added in the areas of data profiling and data matching. Both profiling and matching are now exploiting the DataRush parallel processing engine. According to Jim Falgout (DataRush Chief Technologist), DataRush continues to set records for high performance.The latest record broken was on September 27, 2010 as it delivered an order of magnitude greater throughput than earlier biological algorithm results, performing 986 billion cell updates/second on 10 million protein sequences using a 384 core SGI Ultrix UV1000 in 81.1 seconds.[1] Wow! This enables the entire platform to deliver the basics for a complete data governance infrastructure to those enterprises that know the answer to the question "What are your data quality policies and procedures?" When combined with the data mining open source offering called "KNIME" (Konstanz Information Miner), which featured prominently in numerous use cases at the conference, Pervasive is now a triple threat across data integration, quality, and predictive analytics.

 

In addition to software innovation, end-user enterprises will be interested to learn that Pervasive is also delivering pricing innovations. Client (end user) enterprises will be unambiguously pleased to hear about this one, unlike some uses of the phrase "pricing innovations" that have meant gaming the system to implement price increases. Instead of per connector pricing, the classic approach for data integration vendors, according to which each individual connector costs an additional fee, Pervasive provides all of its available connectors in DI v10 Cloud Edition for a single reasonable monthly charge. The figure that was given to me was $1000 a month for the software, including all the available connectors. And remember, Pervasive is famous since its days doing business as Data Junction for the diversity of connectors, across the entire spectrum from xbase class to high end enterprise adapters. For those enterprises confronting the dual challenges of a short timeline to results and a large number of heterogeneous data sources, the recommendation is clear: check this out.


[1] Or further details see "Pervasive DataRush on SGI® Altix® UV 1000 Shatters Smith-Waterman Throughput Record by 43 Percent":  http://www.pervasivesoftware.com/PervasiveNews


Posted November 4, 2010 10:23 AM
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Healthcare and healthcare information technology (HIT) continue to be a data integration challenge for payers, providers, and consumers of healthcare services. This post will explore the role of Pervasive's Data Integrator software in the solution envisioned by one of the partners presenting at the iNExt, Misys Open Source Solutions (MOSS). However,first we need to take a step back and get oriented to the opportunity and the challenge.

Enabling legislation by the federal government in the form of the American Recovery and Reinvestment Act (ARRA) of 2009 provides financial incentives to healthcare providers (hospitals, clinics, group practices) that install and demonstrate the meaningful use of software to (1) capture and share healthcare data by the year 2011 (2) enable clinical decision support using the data captured in (1) by 2013 and (3) improve healthcare outcomes (i.e., cause patients to get well) against the track record laid down in (1) by 2015. Although the rules are complex and subject to further refinement by government regulators, one thing is clear. Meaningful use requires the ability of the electronic medical record (EMR/EHR) systems to exchange significant volumes of data and do so in a way that preserves the semantics (i.e., the meaning of the data).

Misys Open Source Solutions (MOSS) is jumping with both feet into the maelstrom of competing requirements, standards, and technologies with a plan to make a difference. MOSS first merged with Allscripts and then separated from them as Allscripts merged with Eclipsys. MOSS is now a standalone enterprise on a mission to harmonize medical records. Riding on Apache 2.0 and leveraging the Open Health Tools (OHT), MOSS is inviting would-be operators and participants in health information exchanges (HIE) to download its components and make the integrated healthcare enterprise (IHE) a reality. As of this writing, the need is great and so is the vision. However, the challenges are also formidable and extend from the requirements for patient identification, document sharing, record location, audit trail production and authentication, subscription services, clinical care documentation and persistence in a repository. Since the software is open source and comes at no additional cost, MOSS's revenue model relies on fees earned for providing maintenance and support.

Whether the HIE is public orprivate the operator confronts the challenge of translating between a dizzying array of healthcare standards - HIPAA, HL7, X12, HCFA, NCPDP, and so on. With literally hundreds of data formats in legacy as well as modern systems out there, those HIEs that are able to provide a platform for interoperability are the ones that will survive and prosper by value-added services rather than just forwarding data. The connection with Pervasive is direct since the incoming data formats may be in HL7 version 2.3 and the outbound format in version 2.7. Pervasive is cloud-enabled and, not to put too fine a point on it, has more data conversion formats than you can shake a stick at. Pervasive is a contributor to the solution at the data integration, data quality, and data mining levels of the technology stack being envisioned by MOSS. Now and in the future, an important differentiator between winners and runner-ups amongst HIEs will be the ability to translate between diverse data formats. In addition, this work must be done with velocity and in significant volume, while preserving the semantics. This approach will add value to the content rather than just acting as a delivery service.

As noted in the companion post to this one, Pervasive has a cloud-enabled version of its data integration product, Version 10, Cloud Edition. DataRush, the parallel processing engine, continues to set new records for high performance parallel processing across large numbers of cores. Significant new functionality in data profiling and data matching is now available as well, making Pervasive a triple threat across data integration, data quality, and when open source data mining from Knime is included, data mining. [For example, NCPDP = National Council of Prescription Drug Programs; HCFA = Healthcare Finance Authority (the precursor to the Centers for Medicare and Medicaid); HIPAA = Health Insurance Portability Accountability Act; HL7 = Health Language Seven; X12 = a national insurance standard format for electronic data exchange of health data.



Posted November 4, 2010 10:04 AM
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There are so many challenges that it is hard to know where to begin. For those providers (hospitals and large physician practices) that have already attained a basic degree of automation there is an obvious next step - performance improvement. For example, if an enterprise is operating eClinic Works (ECW) or similar run-your-provider EHR system, then it makes sense to take the next step and get one's hand on the actual levers and dials
that drive revenues and costs.

Hospitals (and physician practices) often do not understand their actual costs, so they are struggling to control and reduce the costs of providing care. They are unable to say with assurance what services are the most profitable, so they are unable to concentrate on increasing market share in those services. Often times when the billing system drives provider performance management, the data, which is adequate for collecting payments, is totally unsatisfactory for improving the cost-effective delivery of clinical services. If the billing system codes the admitting doctor as responsible for the revenue, and it is the attending physician or some other doctor who performs the surgery, then accurately tracking costs will be a hopeless data mess. The amount of revenue collected by the hospital may indeed be accurate overall; but the medical, clinical side of the house will have no idea how to manage the process or improve the actual delivery of medical procedures.

Thumbnail image for Thumbnail image for riverlogicjpg.JPG

Into this dynamic, enters River Logic's Integrated Delivery System (IDS) Planner (www.riverlogic.com). The really innovative thing about the offering is that it models the causal relationship between activities,
resources, costs, revenues, and profits in the healthcare context. It takes what-if analyses to new levels, using its custom algorithms in the theory of constraints, delivering forecasts and analyses that show how to improve performance (i.e., revenue, as well as other key outcomes such as quality) based on the trade-offs between relevant system constraints. For example, at one hospital, the operating room was showing up as a constraint, limiting procedures and related revenues; however, careful examination of the data showed that the operating room was not being utilized between 1 PM and 3 PM. The  way to bust through this constraint was to charge less for the facility, thereby incenting physicians to use it at what was for them not an optimal time in comparison with golf or late lunches or siesta time. Of course, this is just an over-simplified tip of the iceberg.

 

IDS Planner enables physician-centric coordination, where costs, resources, and activities are tracked and assessed in terms of the workflow of the entire, integrated system. This creates a context of physician decision-making and its relationship to costs and revenues. Doctors appreciate the requirement to control costs, consistent with sustaining and improving quality, and they are eager to do so when shown the facts. When properly configured and implemented, IDS Planner delivers the facts. According to River Logic, this enabled the Institute for Musculosketal Health and Wellness at the Greenville Hospital System to improve profit  by more than $10M a year by identifying operational discrepancies, increase physician-generated revenue over $1,700 a month, and reduce accounts receivable by 62 down to 44 days (and still falling), which represents the top 1% of the industry.  Full disclosure: this success was made possible through a template approach with some upfront services that integrated the software with the upstream EHR system, solved rampant data quality issues, and obtained physician "buy in" by showing this constituency that the effort was win-win.

The underlying technology for IDS Planner is based on the Microsoft SQL Server (2008) database and Share Point for web-enabled information delivery.

In my opinion, there is no tool on the market today that does exactly what IDS Planner does in the areas of optimizing provider performance.River Logic's IDS Planner has marched ahead of the competition, including successfully getting the word out about its capabilities. The obvious question is for how long? The evidence is that this is a growth area based on the real and urgent needs of hospitals and large provider practices. There is no market unless there is competition; and an overview of the market indicates offerings
such as Mediware's InSight (www.mediware.com/InSight), Dimensional Insight (www.dimins.com) with a suite of the same name, Vantage Point HIS  (www.vantagepointinc.com) once again with a product of the same name. It is easy to predict that sleeping giants such as Cognos (IBM) and Business Objects (SAP) and Hyperion (Oracle) are about to reposition the existing performance management capabilities of these products in the direction of healthcare providers. Microsoft is participating, though mostly from a data integration perspective (but that is another story), with its Amalga Life Science offering with a ProClarity frontend. It is a buyer talking point whether and how these offerings are able to furnish useable software algorithms that implement a robust approach to identifying and busting through performance constraints. In every case, all the usual disclaimers apply. Software is a proven method of improving productivity, but only if properly deployed and integrated into the enterprise so that professionals can work smarter. Finally, given market dynamics in this anemic economic recovery, for those end-user enterprises with budget, it is a buyer's market. Drive a hard bargain. Many sellers are hungry for it and are willing to go the extra mile in terms of extra training, services, or payment terms.



Posted April 5, 2010 11:33 AM
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The rule-making that will determine which hospitals and physician practices are eligible for reimbursement for buying an 'electronic healthcare record (EHR)' is out for public comment (until March 15, 2010). The rules state that the provider must demonstrate 'meaningful use' of a 'certified EHR'. The 'meaningful use' portion has already been parsed to death about a hundred different ways, and is not further discussed in this post. This post is about whether or not the 'certified' is voluntary. The enabling legislation that I will quote clearly states it is 'voluntary'. Yet the proposed rule-making [CMS-033-P (CMS-2009-0117-002)] that implements the reimbursement process reads like the reimbursement requires purchase of a 'certified EHR'. If the EHR is not 'certified', then there is no reimbursement - so 'certified' would be mandatory. This is an inconsistency of numbing grossness.

     The underlying legislative act clearly states the Office of the National Coordinator of HIT and  National Institute for Standards and Testing (NIST) should set up a voluntary program to coordinate, define, and test standards and candidate standards. The key term is 'voluntary'. For example:

 [HITECH Act: Sec. 13101 - ONCHIT

The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following:

''TITLE XXX--HEALTH INFORMATION TECHNOLOGY AND QUALITY

''SEC. 3000. DEFINITIONS. . . . .]

'(5) CERTIFICATION.--

''(A) IN GENERAL.--The National Coordinator, in consultation with the Director of the National Institute of Standards and Technology, shall keep or recognize a program or programs for the voluntary certification of health information technology as being in compliance with applicable certification criteria adopted under this subtitle. Such program shall include, as appropriate, testing of the technology in accordance with section 13201(b) of the Health Information Technology for Economic and Clinical Health Act.' [emphasis added]

[. . . . ]

 

'HITECH ACT Sec. 13201. National Institute for Standards and Technology Testing.

(b) Voluntary Testing Program.--In coordination with the HIT Standards Committee established under section 3003 of the Public Health Service Act, as added by section 13101, with respect to the development of standards and implementation specifications under such section, the Director of the National Institute of Standards and Technology shall support the establishment of a conformance testing infrastructure, including the development of technical test beds. The development of this conformance testing infrastructure may include a program to accredit independent, non-Federal laboratories to perform testing.' [emphasis added]

           If I read this correctly, there is nothing in the HITECH portion of the ARRA [American Recovery and Reinvestment Act (sometimes also known as 'the Bailout')] that requires, mandates, or forces the use of 'certified' EHR in order to qualify for reimbursement.The plain meaning of the word 'voluntary' is available to mere visual inspection. Yet the the rule-making document (not quoted in this post, but see here) goes on-and-on referencing reimbursement is allowed for 'certified EHRs'. That would be a requirement - mandatory - would it not? Am I a tad confused by the alphabet soup, or is this process off the rails? I suspect the latter - and, at the risk of bragging, but if not now, when? - you heard it hear for the first time anywhere. Thus, I am going to say it: Any rule-making that changes 'voluntary' to 'mandatory', 'required', or 'necessary' is at variance with the underlying enabling legislation. Given the complex and dynamic nature of the process, the introduction of such a requirement is the moral equivalent of a typographical error and usefully should be corrected - typographically. We can discuss more conspiratorial, if not sinister, interpretations in a future post - that's where the real fun begins - but for the present, I wish to be cautious. If any reader can explain this discrepancy, please post a comment and get in communication with me. The matter is complex. Anyone can make a mistake - including a typo - perhaps I have overlooked something. Meanwhile, you can see how this implies a powerful and free market empowering position vis a vis 'certified EHR'. Where did this 'certified' come from? Stand by for update on that position.  


Posted February 12, 2010 7:30 AM
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The game is afoot. On Wednesday December 20, 2009, the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services, Electronic Health Record Incentive Program, issued its proposed criteria for the meaningful use of certified electronic healthcare records (EHRs).

      In every case, the healthcare provider (physician, professional, hospital, and so on) is the entity that is eligible for reimbursement and which must demonstrate meaningful use. The mere purchase of a software/hardware package or system integration project - regardless of its status as certified or not - is not sufficient. The technology is required to be used in a way that, in effect, adds value in transforming the delivery of healthcare services. In this case, 'value' consists in capturing clinical data - for example, vital signs - in electronic form, using it for clinical decision support, and gradually enabling interoperability, usability, affordability (cost reduction), and applying that information to the solution of individual and communal healthcare challenges. As currently stated, the criteria focus on a result and a measure rather than a "how to" or method of demonstrating the result. For example, entry level criteria mandate the collection and recording of  patient demographics, record vital signs, and maintaining a list of active medications for at least 80% of unique (individual) patients admitted. The later is basic data processing, though other criteria are more complex and demanding. The message? For those lagging adopters, it's time to throw away paper charts and advance to the twentieth century.

      The proposed rules implement the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). At this point, the status of the rules are 'a proposal' and a request for public comment from healthcare professionals, healthcare consumers, and everyone - the public at large. However, the expectation is that something substantially similar to this 556-page proposal (Pub. L. 111-5) is what will actually be implemented, even if extensive minor changes are incorporated and the date slips a tad.

     It is this proposal that provides the definition of 'meaningful use' and incentive payments to eligible professionals (EPs) and eligible hospitals participating in Medicare and Medicaid programs for adopting certified electronic health record (EHR) technology. The proposed rule defines the criteria an EP and eligible hospital must meet in order to qualify for the incentive payment and the calculation of the incentive payment amounts. The proposed rule also defines payment adjustments - here 'adjustment' means 'penalty, fee, fine, or deduction' under Medicare for failing to implement meaningfully use certified EHR technology.

            This proposal offers both a carrot - substantial reimbursements - as well as a stick. The stick? Those EPs and hospitals that do not meaningfully use an EHR by 2015 will find their reimbursements cut significantly by Medicare.

     The proposal furnishes answers - in detail and in draft - to answer the question, 'So what are the rules anyway?' As usual, the devil is in the details.

Congress specified three types of requirements for meaningful use: (1) use of certified EHR technology in a meaningful manner (for example, capturing data about who smokes cigarette, vital signs, electronic prescribing); (2) that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and (3) that, in using certified EHR technology, the provider submits to the Office of Secretary (HHS) information on clinical quality measures.

The goal is to make meaningful use of certified EHR technology a foundation for healthcare that is patient-centered, evidence-based, prevention-oriented, efficient, and fair. The matter of who or what gets to certify what entity is already a contentious one, and will be addressed in forthcoming posts in this blog. Meanwhile...

Starting in 2011 - which basically means 'get ready now' - the first stage of meaningful use focuses on the electronic healthcare record (EHR) and electronically capturing health information in a coded format; using that information to track clinical conditions and communicating that information for coordination of care, implementing clinical decision support software and processes, enabling disease and medication management; and reporting clinical quality measures and public health information.

Beginning in 2013, stage 2 raises the bar on the use of health IT for continuous quality improvement at the point of care. The exchange of information in the most structured format possible is required, for example, the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, and other diagnostic data). In addition, the criteria will be applied broadly to inpatient and outpatient settings.

Beginning in 2015, stage 3 criteria focuses on improvements in quality, safety and efficiency, enabling decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.

  Do not be scared off by the size of the report. There is an amazing amount of redundancy and repetitions as befits a government report. However, there still is a couple hundred pages of meaty material under any interpretation. What are your plans for the weekend? You can download the full document at

http://www.federalregister.gov/articles/2010/07/28/2010-17207/medicare-and-medicaid-programs-electronic-health-record-incentive-program



Posted January 6, 2010 9:12 PM
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