April 7, 2009
I am writing this blog on my way back home from www.himss.org show in Chicago, while a tingly chill crawls down my back. It’s a creepy feeling of déjà vu. Even worse, it feels like the movie Groundhog Day where the main character keeps waking up on the same day, same date, never able to get to tomorrow. Everything he was able to achieve during the day is erased, and he has to do it over, and over, and over again. This was the feeling I got as I walked the show floor and kept asking myself questions such as:
- Where are the open technology standards?
- Where is the transparency?
- Where is the common sense that business requirements, not vendors, dictate the rules?
I thought we addressed all these basic truths decades ago? Ah, forgive me, I must’ve been thinking about the wrong industry. I was talking about the Financial Services vertical, where after the dark ages of 70’s and 80’s, we finally entered the renaissance age of enlightenment, standards, openness, and transparency. Well, while we may be past the King Arthur times in Healthcare IT, we are not too far from it, probably just approaching the days of Charlemagne trying to unify Western Europe.
As I explored the Healthcare IT show I found the state of industry BI where
- Errors abound! Information Management Systems and CPOE (Computerized Physicians Order Entry) applications account for a staggering 84% of 43,372 USP MEDMARX Computer Technology-Related Harmful Errors (2006)
- Proprietary, closed architectures still rule. Hospital information management applications are often based on hierarchical databases that do not speak common query languages like SQL or MDX — the basis for all modern BI tools (even though some BI tools are beginning to roll out XQuery language functionality capable of reporting from XML data structures). Even worse, most of these applications are not architected with separate data and application logic tiers. Sounds familiar?
- There is no data transparency. Applications with proprietary, hidden data models do not allow for a plug-and-play interface with ETL (Extract, Transform, Load), CDC (Change Data Capture), or other standard data integration technologies. Such an environment breeds a swarm of small consultancies founded by ex-developers of these proprietary, closed hospital information applications. They take advantage of the insider scoop on how the guts of these applications work, and make a living building custom interfaces for their clients.
- Standards are incomplete. Data exchange standards like HL7 only work for about 80% of the content (and that's for administrative, but even less so for clinical data) — the rest must be custom integrated every time.
- Huge chunks of MDM are missing. MDM (Master Data Management) — a key to effective BI applications — works mostly for patient information, and maybe billing codes, but not for anything else, like drugs (good luck trying to find a standard code for 200mg ibuprofen gel coated caplets), conditions, and treatments (there is no such thing as a “standard treatment” for a particular ailment — it is all subjective). For example, one senior Healthcare IT manager tells me that Glucose test is coded differently in every single lab system she looked at, so her team spent countless hours coding mapping tables.
- The world is very vendor-, not user-centric. True, most of the state-of-the-art (translation for those unfamiliar to the world of Healthcare IT: state-of-the-art = proprietary) healthcare IT applications are very powerful and function rich, but few of the vendors I talked to seemed to care about integrating with other vendor applications.
As a result, all of the healthcare IT execs I managed to pry away from listening to yet another pitch from a vendor that was all about “Me! Me! Me!” named three top challenges that they all face every day: integration, integration and integration. Another Healthcare IT executive tells me that it took them about 3 months to write database, application and GUI logic for their hospital EMR system, but it is taking them years and years (still going strong) to integrate pharmacy and lab data even within their own hospital network! She defines standards like HL7 purely as communication standards, not content standards, the lack of which is the real culprit. Until this status quo changes, I do not see a bright future for such noble and highly needed industry initiatives as:
- Nationwide integrated Electronic Medical Records (EMR)
- Translational Research — linking patient care and pharmaceutical research applications, processes and data
- Pay For Performance — Medicare and Medicaid driven mandates to link procedures and treatments to the actual improved health conditions of the patients
There’s no rocket science behind these initiatives and drivers, but they will not materialize until the ice of proprietary and closed architectures is broken. What will it take to change all that? Surely not the $19B of questionable spending that the Obama administration is throwing at the problem (which is really just an extension of http://www.hhs.gov/healthit/ initative started by the Bush administration back in 2004). Just look at the $22B that UK allocated in 2002 to similar initiatives to transform its National Health Service information infrastructure. Proving once again that federally managed projects seldom work, in January 2009 the British Committee of Public Accounts (similar to the US GAO) released a less than stellar progress report citing four to five year delays, major contractors bowing out of the projects, and, most importantly, eroding support from the key stakeholders — physicians, dissatisfied with “essential systems that are late or when deployed, do not meet the expectations of clinical staff”. Surely, we should learn from the mistakes of others, not our own.
No, nothing short of free market competition and an IT practitioners revolt will change that. And there’s hope and light at the end of the tunnel:
- Battle hardended industry veterans are entering the industry. I did see a lot of familiar faces at the show from IBM, Informatica, Information Builders, Microsoft, MicroStrategy, Oracle, SAP, and Sybase. I know that these vendors believe in open architectures and transparent design, so hopefully the rest of the industry will learn form them. I hope that IT managers will see the benefits of these open, interoperable technologies, where integration is a no-brainer, start migrating towards them, and leave the proprietary and closed solutions in the dark ages where they belong.
- There’s tons of competition. I counted at least several hundred vendors at the show! And competition breeds health and innovation, especially when independent research vendors, like www.KLASresearch.com are beginning to provide some transparency. They poll end users and IT staff for their opinion on usability, functionality, stability and other ratings of these proprietary systems — so such vendors cannot hide behind closed doors for long. Just wait till I do a Forrester Wave on these vendors!
- This is truly a life and death opportunity! Failure is not an option here. Various studies like the one published recently in the Archives of Internal Medicine continually show direct relationship between poor IT and patients' lives! This particular study found that even a 10% increase in automation of clinical notes and records resulted in 15% reduction in patient deaths (data from 41 Texas hospitals involving over 150,000 patients).
What can you, a Business Process and Application (BP&A) professional, do? While I could write a series of epic novels about everything you could do you improve the state of Healthcare IT, I have to get onto my flight in a few minutes, so I will be merciful and just share my point of view on a few BI specifics:
BI is not a panacea, but it's a start. True, BI is useless until data is clean, integrated and aggregated. But you should not wait for that to happen before implementing your BI solutions. Just the opposite. Use BI as a perfect tool to start exposing your data problems, and demonstrate to key stakeholders what data issues you have and how you can start addressing them. Results from BI reports are a great supporting evidence for justifying data integration project budgets.
Leverage our BI related Waves. Use and leverage Forrester's BI Wave, ETL Wave, and DW Wave when evaluating Healthcare BI solutions. If data integration, data cleansing, data warehouse, reporting, OLAP, and dashboard tools are not built on one of these standard and open technologies, that’s a huge red flag! At the very least, use the criteria in our Waves to evaluate, score, and rate the BI vendors you are shortlisting.
- If it’s not plug-and-play, it’s probably bad news. Use compatibility and out-of-the-box integration with these leading BI tools and platforms as a measuring stick to evaluate other Healthcare IT applications. If you see that you need to write “custom” scripts to extract data from the application so that one of these leading BI tools can be used to analyze the data — that's another big red flag. Remember, you are in the business of improving (and even saving!) patients’ lives, or analyzing the performance of your healthcare provider, and not in the business of developing custom scripts and extracts.