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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!

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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.

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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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I had a chance to talk with Yves de Montcheuil, VP of Marketing, about current events at Talend and its vision of the future.

Talend addresses data integration across a diverse array of industry verticals. Its inroads in healthcare will be of interest to readers of this blog. As noted elsewhere, healthcare is a data integration challenge ( healthcare data integration). For example, at Children's Hospital and Medical Center of Omaha (NE), heterogeneous systems are the order of the day. The ambulatory EMR generates tons of documents. These need to be added to its legal medical record system, MedPlus Chartmaxx. On occasion, some of those documents error out before being captured to the patient's chart in Chartmaxx. This is clinical information impacts clinician decision making, and must be filed to the appropriate patient's record in a timely manner, supporting patient care quality. Talend synchronizes such processes across clinical systems. It providers data transformations, notifications and, in this case, exception processing, furnishing a level of functionality that previously required a larger and more expensive ETL tool from a larger and more expensive software vendor. This is the tip of the iceberg; and Talend is now the standard at the enterprise for data integration and data quality. This is obviously also the process in which to perform data quality activities - data profiling, data validation, and data correction. Data validation occurs inside the data stream, and any suspect data is flagged and included in a report that is then processed for reconciliation. The ability to perform data quality controls and corrections across them makes the processing of data faster and smoother. It should be noted that, although I drilled down on this example, Talend has numerous high profile wins in healthcare (accessible on its web site here.)

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Taking a strategy from the play book of its larger competitors, but without the pricing mark up, Talend is developing a platform that includes data quality in the form of Talend Data Profiler and Talend Data Quality, the latter, of course, actually able to validate and correct the errors surfaced. The obvious question is what is the next logical step?

Several possibilities are available. However, the one engaged by Talend - and its a good one - is the announcement (here) of the acquisition of a master data management (MDM) software firm, Amalto Technologies, and plans to make it a part of its open source distribution in 2010. This is a logical move for several reasons. First, data integration and data quality (rationalization) are on the critical path to a consistent, unified view of customers, products, providers, and whatever master data dimensions turn you on. The data warehouse is routinely referred to as a single version of the truth. Now it turns out that there is no single version of data warehousing truth without a single version of customer, product, location, and calendar (and so on) truth to support the data warehouse. (This deserves a whole post in itself, so please stand by for update on that.)

While the future is uncertain, I am betting on the success of Talend for several reasons. First, the approach at Talend - and open software in general - simplifies the software acquisition process (and this regardless of any price consideration). Instead of having to negotiate with increasingly stressed out (and scarce) sales staff, who need to qualify you as a buyer with $250K or $500K to invest, the prospect sets his own agenda, downloading the software and building a prototype at its own pace. If you like the result and want to scale up - and comments about the quality of the software are high, though, heavens knows, like any complex artifact, there is a list of bug fixes - then a formal open source distribution is available - for a fee, of course - with a rigorous, formal service level agreement and support. Second, according to Gartner's November 25, 2009 Magic Quadrant for Data Integration, available on the Talend web site for a simple registration, Talend has some 800 customers. I have not verified the accuracy of this data, though there are logos aplenty on the Talend web site, including many in healthcare, and all the usual disclaimers apply. Talend is justifiably proud and is engaging in a bit of boasting here as open source gets the recognition it has for some time deserved Third, Talend is turning the crank - in a positive sense of the word - with a short cycle for enhancements, currently every six months or so. With a relatively new and emerging product, this is most appropriate, though I expect that to slow as functionality reaches a dynamic equilibrium a couple of years from now. There are some sixty developers in China - employees of Talend, not out sourced developers - reporting to a smaller design/development team of some 15 architects in France. Leaving aside the formal development of the defined distribution of the software for the moment, the open source community provides the largest focus group you can imagine, collecting and vetting requests and requirements from the community. As in so many areas of the software economy, Talend is changing the economics of data integration - and soon MDM - in a way that benefits end-user enterprises. Watch for the success of this model to propagate itself virally - and openly - in other areas of software development.  Please let me hear from you about your experiences with Talend, data integration, and open source in all its forms.


Posted December 11, 2009 9:47 AM
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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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