In The World Health Organization's last ranking, the United States ranked 37th – just behind Cost Rica and just ahead of Slovenia and Cuba – even though the U.S. has the best medical schools and some of the most advanced information technology. In addition, healthcare in the United States costs twice as much as in other advanced countries, yet U.S. healthcare is ranked lowest in its peer group across most measures, including quality, access and efficiency.
The Obama administration is counting on healthcare information technology to help turn this situation around. The 2009 Federal Budget and stimulus plan provides incentives and funding for Electronic Medical Record (EMR) and Electronic Health Record (EHR) initiatives. EMR is an essential ingredient to increasing data quality, streamlining business processes and providing information access within the enterprise while EHR extends these essential assets by making electronic health information interoperable between health enterprises via standards like HL7.
Beyond these important EMR/EHR initiatives, there are other IT projects that can help healthcare providers maximize quality and minimize costs in the short term. Chief among them are business intelligence (BI), a type of software that supports strategic and operational decisions even as you implement EMR, and performance management (PM) technology, enabled by comprehensive integration technology. Performance and quality are critical to the success and, in some cases, the very survival of healthcare organizations.
Healthcare organizations need a way to bridge the gap between the promise of EMR and today’s reality. The solution is to use relatively inexpensive, best-of-breed technologies that leverage existing information assets and can simply “plug in” to a hospital’s existing infrastructure. Not only does this approach ensure the lowest cost and shortest time to value, but it also “future proofs” these investments. The business imperatives of these initiatives are as follows:
- Managing performance at all levels: service lines, departments, physicians
- Improving patient safety and clinical outcomes
- Maximizing operations: facilities, technology, patient satisfaction
- Reducing costs: labor, supplies, revenue cycle
- Driving growth with new revenue opportunities
Optimizing Performance with Business Intelligence Technology
In order to maximize hospital performance, business intelligence solutions must be available across the organization from both a strategic and an operational perspective. Objectives and initiatives should be described in cause-and-effect chains called strategy maps and then cascaded throughout the organization so each participant understands how they will be measured and how their contributions relate to overall goals.
Once this architecture is in place, personalized dashboards can be created that alert workers to trends and problems as they occur. These users can drill down to uncover the root causes of various performance problems. Meanwhile, managers can analyze effectiveness over time to further refine strategies and put initiatives, also known as gap projects, in place that are directed at improving performance. This is called operational performance management and leads to performance improvements due to improved alignment. There is truth in the adage, “What gets measured gets done.”
Operational business intelligence involves extending actionable business information to many different types of employees throughout the enterprise. It improves business performance by providing workers with actionable information so they can make better decisions. The need for this type of pervasive intelligence has become progressively more important. The value in most companies has shifted from the efficient use of tangible assets to the effective use of human, organization, and information capital. This shift validates the need to embed real-time information into operational processes for front-line workers across the enterprise. Once workers are equipped with this knowledge, they can reduce errors, increase efficiency, improve service and make more knowledgeable, evidence- based clinical decisions.
The Democratization of Information
Achieving a high-performance healthcare enterprise requires an environment where performance and operational information is shared by everyone who needs it in a transparent manner. Government agencies, insurers and Pay for Performance (P4P) initiatives require healthcare providers to maintain transparency and accountability. Transparency creates an environment of trust that empowers all stakeholders to collaborate in a proactive way to solve operational problems while constantly striving for more innovative ways to improve performance and achieve value. The old axiom that “knowledge is power” must be revised for the highly interdependent world of healthcare to “knowledge is power only when it is shared.”
Better alignment and sharing of goals – bolstered by the availability of relevant information – enables stakeholders to work together to close the gap between strategy and operations. Once you provide performance management coupled with operational BI to everyone, you can achieve this type of strategic business intelligence. Then, everyone in the organization can make decisions that align with corporate strategies and goals.
A properly configured performance management framework provides a secure, role-based environment for managing metrics, defining strategies, and creating scorecards. When deployed to managers and stakeholders throughout the organization, this type of technology helps managers align business goals with operational processes. The graphic below depicts how tight integration of business intelligence and performance management functions can improve decision making and positively impact performance.
Of course, when it comes to making information useful and actionable, different users have different needs. For example executives and administrators need scorecards and dashboards with key performance metrics so they can make data-driven decisions to identify underperforming areas, spot trends, and justify changes in budget, staffing levels, and resource utilization. Managers need to monitor emergency department and operating room activity to make schedule and staffing adjustments when there are delays or spikes in demand. Analysts need to slice and dice information across systems for efficient planning and forecasting. Doctors, nurses, and support staff need self-service dashboards that provide clinical information at the point of care.
Getting Everyone on the Same Page
Getting various stakeholders with different perspectives to act in harmony to support the broad goals and strategies of the organization is a continual challenge. As we’ve seen, a performance management framework helps foster a “culture of accountability” in which each stakeholder has accurate information to support the organization’s goals in every department. But driving success has less to do with technology than it does with implementing the goals, initiatives and cultural changes to support each organization’s strategy. Healthcare providers need an information framework to support the right measurements, incentives and processes for each stakeholder based on their roles and areas of accountability.
EMR/EHR initiatives have tremendous potential, but you can only reach that potential through incremental initiatives. Often these initiatives are executed one department and one process at a time as part of a cohesive, overall plan. In most cases, short-term projects with incremental goals yield the greatest benefits.
But how do you know if you are on the right path? Are you sure everyone understands their roles in these initiatives? Healthcare providers have very complex organizations, which means enterprise goals and strategies must be applied to many interdependent areas such as physical units (nursing, OR, ED), ancillary functions (radiology, labs, and pharmacy), service lines (cardiology, orthopedics, neurology) and administrative functions (admitting, patient accounting).
Healthcare providers are organizationally complex and so are their IT infrastructures, which often include dozens of disparate systems. BI applications must draw from these systems to enable organizational decision-making. For example the revenue cycle relies on ADT, insurance contract information, accurate HIM coding, charge capture from multiple clinical systems, and other data.
Obstacles to Success
Many clinical systems lack decision support, in which data is primarily used to comply with regulations and defend against lawsuits, rather than to improve care. Valuable time and energy is spent managing data as opposed to understanding patient needs.
One challenge facing healthcare providers and executives is selecting key performance indicators (KPIs) that support strategic priorities. Without implementing a comprehensive framework for managing performance there is no real way of incorporating operational effectiveness and efficiency into an institution’s overall goals. Developing key performance indicators and regularly monitoring progress is vital to an organization’s continued health. KPIs give a competitive edge to institutions by allowing them to monitor effectiveness across the continuum of care. Implementing a robust, reliable solution to track real-time measures yields concise and efficient management, which are the building blocks for performance improvement, revenue return, and quality control.
According to industry studies, the typical enterprise only uses 20 percent of its data and only provides business intelligence capabilities to 20 percent of its employees. Deluged with data and saddled with disconnected, closed systems, healthcare organizations are even further behind. In this setting it can be a life-and-death problem: most healthcare employees are knowledge workers, so having accurate, actionable information is extremely important. It’s also a business problem: even small improvements in labor productivity, clinical efficiency, insurance denials, supply chain management, and medical technology utilization can result in millions of dollars in annual savings.
What are the ramifications of not providing business users with actionable information? Another preventable medical error, another missed chance to improve a clinical practice, another unbilled charge, another insurance denial, another unhappy patient, another physician lost – the list is endless.
The time is ripe for change. Massive government initiatives falling out from the
Federal Stimulus Plan all position healthcare information technology as the key to improving quality and reducing costs.
Putting Electronic Records in Perspective
EMR and EHR are incredibly important to today’s healthcare industry. These electronic records solve two types of problems. The first type involves streamlining business processes by making disparate information systems work together. These solutions reduce costs by eliminating manual processes. They fall into two general categories:
- Solutions that automate business processes within an organization such as core HIS with ancillary services. This class is commonly referred to as Business Process Automation or BPA. It enhances electronic records in the following ways:
- To deliver real-time lab results
- To reduce administrative costs
- To reduce errors
- To streamline healthcare operations
- Solutions that automate processes between organizations such as between providers and payers. This class is commonly referred to as Business to Business or B2B. It is applied to EHR in the following ways:
- To improve cash flow with payers
- To improve supply chain efficiency
- To improve health agency communications
- To improve information sharing among provider organizations
BI technology addresses this second class of problems by improving decision making. Here the role of EMR/EHR is less direct and the benefits are often more difficult to measure. While the promise of electronic records is to allow for better quality information with easier access, the information is organized only by individual patients. In order to further leverage the value from these records, patient-centric information needs to be aggregated and combined with clinical, financial and administrative information. Aggregating information via dashboards yields powerful insights for reducing costs, increasing efficiency and improving the quality of care.
Sizing Up the Cost of EMR/EHR Initiatives
Most EMR/EHR efforts represent massive undertakings. The biggest challenges are not even technical or financial even though some projects are being delayed in 2009 due to severe drops in revenues and available capital. The bigger challenges are cultural and legal, stemming from the competing interests of patients, hospitals, doctors and payers. Compelling benefits and massive Federal spending will help move these projects forward but the effort will suffer many fits and starts. It may be years before providers see a return on these massive projects.
A good comparison is the adoption and evolution of enterprise resource planning (ERP) systems in commercial enterprises, which rivaled EMR/EHR in hype, high cost and long lead times. ERP systems also replaced disconnected systems with tightly integrated applications to streamline business processes and provide higher real-time quality information. But ERP implementations often struggled with huge time and cost overruns. Much of the potential has yet to be realized even in manufacturing where best practices from efforts like Six Sigma, TQM, and Lean have matured over 50 years. This has been largely due to weak decision support and relatively closed architectures for inter-company process integration. In the world of healthcare, where there are fewer best practices and many entrenched special interests, reaching consensus and moving forward may prove much more difficult.
Yet healthcare organizations must address these challenges if they are to survive and prosper. Improving quality and patient outcomes, reducing costs, and increasing revenue opportunities are essential, and these issues must be addressed now. While electronic medical records may eventually deliver tangible returns, waiting for the promised benefits is like waiting for a brain surgeon to arrive to treat a serious head injury: if the surgeon doesn’t get there in time, the patient may die on the operating table.
A Fresh Take on Performance Management
Good healthcare solutions go beyond older performance management initiatives, which only manage performance retrospectively. This “rear view mirror” approach is typically focused on financial measures. In order to improve performance, leading indicators of performance need to be managed by looking ahead through “dashboards” at operational, quality, service-oriented measures that ultimately impact financial performance and growth. Scorecards for key operational functions should be supplied in conjunction with a data model that supplies healthcare metrics, presented through function-specific dashboards and reporting templates. A mature, industry-specific BI solution helps each department to manage the operational processes that improve performance on a daily basis. This allows each department to make more knowledgeable and timely decisions without losing sight of the broader strategies and goals, as illustrated below.
Even automated performance management applications do not typically integrate with the BI functions required to support operational processes for improved decision making. This lack of true pervasive performance management/business intelligence does not provide context between the corporate goals, strategies and the operational decisions.
Most PM products do not integrate analytic functions with dashboards and scorecards. This lack of integration inhibits the natural data discovery process that leads to true insight, which in turn leads to better decisions. Performance management that is not integrated with mature BI functionality also requires greater administration and does not easily scale beyond a few power users, limiting the potential for better decision making.
Think Big, Implement Small
These projects complement EMR/EHR plans by integrating relevant, high-quality data. They support process-improvement initiatives that mobilize the organization to leverage EMRs. However it is important to evaluate these projects with an eye toward how they fit in to broader business and IT strategies.
The benefits of digitizing medical information are clear to most stakeholders. What is not clear is how healthcare providers can derive maximum value from these initiatives by leveraging the data in productive and intuitive ways. Providers must continue to manage costs, operate efficiently and provide quality care. Implementing a business intelligence environment that provides strategic, analytical and operational information to everyone involved in the continuum of care provides the best opportunity to optimize performance and quality.
SOURCE: Bridging the Gap between the Promise of EMR and Today