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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!

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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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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


Posted January 6, 2010 9:12 PM
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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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To be sure, the USA is not the Sudan. The USA does have a system. Medical innovations are redefining the limits of what is possible in healthcare - biologic "miracle drugs," minimally invasive fiber optic procedures, robotic surgery, powerful magnetic resonance imaging (MRI) machines, and emerging prospects of personalized medicine. These innovations are enormously valuable, incredibly expensive, and enjoy wide public support. Count me in! Yet there are significant "buts"... Much of the healthcare technology is isolated, under utilized, and mis-directed by being located behind information technology (IT) systems that are years if not decades behind the curve. Even when the information technology is upgraded - say, in order to capitalize on federal incentives - it is sometimes used to "pave the cow path." In other words, lay down a veneer of GUI-based modernity over a workflow that is otherwise distinctly 1950s in its organizational and informational design.

When the patient looks at the doctor taking handwritten, paper-based notes; when she tries to get an x-ray sent from the facility to a specialist - and finds it is easier to walk it over in person; when a member of the family is out of town and requires a record from his healthcare file; when a patient or provider tries to get an accurate, committed answer about whether a treatment is reimbursable by a payer - then the modern operating room and laboratory seem less modern and indeed are held in check by a back office, workflow, and organization design that is distinctly prior to the invention of automation. In some cases, these are symptoms of a non-existent information infrastructure, and, in others, of one firmly rooted in the past. Unless explicitly addressed, they represent the default future - more of what we are already doing. We have highly trained doctors and equipment trapped on islands of information separated by manual processes, IT systems with robust 1980s architecture, policy-based turf delimiters, and sneaker networks - remember that? Get on your sneakers and carry the diskette (now a CD) over the connecting bridge between buildings on foot. A bold statement of the obvious: The IT system is due for an upgrade. IT is a lightening rod for policy and organizational transformation that is on the horizon and closing fast. However, the emphasis in this article is on the IT aspects. You will know we are making progress when the IT system supports -

Coordination of care (COC): Note that here "coordination of care" refers to multiple medical specialists in different locations accessing the same patient information. It is important to make this distinction since "coordination of care" also came to mean "reduction or denial of service" by payers, taking on a politically-charged meaning that it should not really have. This time COC does not mean reduced payments for doctors or services for patient like it did in the 1990s. This time it means doctors and care-givers work together using high bandwidth networks and accurate databases to mange complex conditions presented by individuals in context. In a commercial business context, this kind of coordination would be called "customer relationship management" (CRM), including a single view of the customer. Doctors and healthcare providers are smart people - very smart - and this means they will readily learn and adapt when a new possibility is presented that enables improved patient care, accountability, transparency, and reduced risk.

Computational resources available at the point of service: The goal is to access and use information to reduce uncertainty in the examining room, patient bedside, or ambulatory facility. Nevertheless, where even a single life is at stake, automation requires supervision and approval by human (medical) intelligence. This is the value of the collaboration between bar-coded prescriptions, nurse identifiers, and clinical decision support software "double check" prior to administering drugs. A few high profile cases where potentially fatal medication mix ups were caught and prevented - or, unfortunately, not prevented - is a powerful justification. The drill requires that patients, medications, and providers be unambiguously identified and authenticated by a unique, barcode-like id. Then when the nurse goes to change the intravenous drip, he or she must scan the medication, scan their own id, and scan the patient's id - as easy as 1-2-3. If potassium chloride has been mistaken for sodium chloride, then the system catches the error, and the lethal mistake is avoided. Note also the upstream implications for physician order entry and physician accountability. The doctor (or her or his assistant) must have entered the order for the medicine into the clinical management system and it must be available in a real time or near real time way. Anything that reduces risk in a system already stressed out by the need for tort reform in an overly litigious society will be embraced and exploited.

The value of database resources is recognized and implemented. This is taken for granted in many business contexts. Thinking in healthcare is still catching up. A case in point. When Hurricane Katrina put the city of New Orleans under nine feet of water, including the medical records, the need for disaster recovery was demonstrated in spades. Of course, both paper and electronic records were submerged. However, in some cases - such as the Veterans Administration - an off site, distributed back up of the electronic records was available. Those veterans were able to receive up-to-the-minute care in Houston or other evacuation site, since the electronic version was actually located in a different city or it was restored and available within days. So some things are working right, albeit intermittently across the system. The recommendation? Get to a standard relation database. A centralized repository or a distributed one that appears and functions in a centralized way is critical path for coordination of care. Maybe I need to get out more, but the number of so-called modern, run-your-hospital systems that implement the admittedly powerful b-trieve database, Mumps, is a significant symptom - and data point. Mumps is not bad, but it is a curiosity. There is a clear cost reduction opportunity in surmounting the technology lock in such a "one off," proprietary (legacy) choice in favor of an open approach where "open" extends to de facto standard market offerings from IBM, Microsoft, Oracle (to name just the "big three").

Personalized medicine gets traction. In a commercial business context, this would be called "business intelligence," using data to track trends, influence markets, and create opportunities. I hasten to add that the challenge is to use comparative effectiveness research (CER), which is related to pay-for-performance, in an accurate and timely way to identify winning treatments rather than to find an excuse to deny service. For example, Genentech/Roche's Avastin costs $50-$100,000 per year of treatment but works in fewer than 50% of patients. A relatively simple upfront test for Avastin response could save as much as $6 billion per year if all nonresponders could be identified and not targeted. The potential cumulative savings are substantial. (Data taken from - http://www.genengnews.com/specialreports/sritem.aspx?oid=64921206 ) This is a high bar, and there is still a lot of data modeling, data collection, data cleansing, and system integration to be done before meaningful predictions can be made about treatment effectiveness.

Social factors and usability are integrated. Short cuts for expert and advanced users of the system to fast forward through steps that are already familiar are required. Expect healthcare providers make for demanding users - and they should be. They require support accordingly. We are learning a lot from practices at the Veteran Administration (VA) and at the Mayo Clinics, including the stunning insight that automation is most useful only if it is used; that automation can be inflexible, requiring doctors and providers to accommodate the rules. The latter can be misperceived as an affront to the sovereign authority of physicians operating in the "command and control" practice model. Usability testing and user (physician) buy in remain on the critical path.

Patients and consumers take responsibility, and do this regardless of the work-in-progress nature of the new and existing IT systems. Lest the reader imagine that IT is a silver bullet, there are lessons here for healthcare patients (consumers) too. Regardless of what comes out the US Congress, this quarter or in the future, consumers are held accountable for their health. The default is to be held accountable by life - getting sick. We simply cannot afford unhealthy lifestyles. Eating right, regular exercise, following the advice of one's doctor (apparently about one half of patients actually do so), and participating in wellness and treatment are the order of the day. Obviously this is easier said than done, especially for stressed out consumers, working two jobs - or none at all. Yet it is critical path. You don't feel like exercising? Instead of going to the refrigerator, get on your sneakers and get going! Even then there are no guarantees - people who "live right" still get sick or have accidents. That is why insurance was invented - get everyone into the pool and spread the risk. Still, do I smell an economic opportunity for gyms, work out shoes and gear, and fruit and vegetable merchants? Obviously there's lots more to be said - but let me acknowledge this article is already way too long for a blog post, and will be republished as a standalone article. However, I see value in launching a "prototype" - just to "get it out there" and get instant feedback - so let me hear from you. The title is intentionally provocative ... meanwhile, I've got to get up out of this chair, follow my own advice, and get some physical exercise.

Posted November 23, 2009 1:56 PM
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