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For other articles and previous issues click here. November 29, 2004 Data
Warehousing — How Important Is It? Plucking data from a central location sounds like a fabulous idea, but without a specific purpose in mind, it could prove to be quite inefficient. One way to look at health information technology is through the dialectical tension between the big idea (total integration) and a bunch of smaller ideas (a number of different systems set up for specific purposes). The trouble with the latter is it keeps proliferating and tends to go off in different directions; therefore, the idea of integration is appealing. Data warehousing falls into the big ideas category. It may be big, but it’s simple. Take all your information and put it into one database where it can be conveniently accessed by everyone in the organization. Before zeroing in on that concept, it might be helpful to first take a look at another big idea from a few years back. The automotive industry was tired of spinning its wheels as it tried to sort out different “islands of automation.” Along came Computer Integrated Manufacturing (CIM) to organize production, but whenever it started to tie them together, a new island would emerge. General Motors decided to lick the problem once and for all by building a complete plant from scratch, with all the computerization integrated in every respect. The day after the $5 billion plant opened, it was obsolete. Replied the vice president of CIM, “We forgot to factor in the human element.” Data warehousing is in a similar situation. It’s an idea that’s been around healthcare a long time, but according to experts it can be rather porous. It means different things to different people in just how it is implemented, the degree to which it is implemented, the tools used, what is accomplished, and so on. Data warehousing conjures visions of high-tech computer gadgetry designed solely for electronic health records (EHRs). However, paper records also figure into the equation. Mark T. Rempe, vice president of health information services at Iron Mountain in Collegeville, Pa., says that of the more than 1,300 hospitals he deals with, the majority have paper records or a hybrid between paper and electronic records. Rempe is hardly computerphobic and says he fully supports the movement toward electronic record keeping, but adds that paper and/or a hybrid system is not necessarily a bad thing. He suggests that hospitals take a cautionary approach. “Many hospital officials feel a pressure to move into more and more technology when they have not clearly identified the problems they are trying to solve,” Rempe says. The fact is that if you have paper record keeping, you already have an integrated system. Once you introduce an EHR, you have two. The holy grail, of course, is to have a paperless system. But people have a tendency to believe that information is not “real” unless it’s documented on paper. This has led to a proliferation rather than reduction of paper. The use of computerization for information storage is, says Rempe, “a waste of time and money.” Many hospitals will strive to get all their medical records online, then convert them to paper for legal, storage, or other secondary purposes. Or people will put their information on a CD and put it in a box for storage. “It’s like microfilming,” Rempe says. “It’s a static format, which is an expensive and unnecessary [process].” Technology should be employed, Rempe maintains, with a specific purpose in mind, such as solving workflow problems. And, he adds, this isn’t necessarily a function of hospital size. Rempe says it is fine if a large hospital works efficiently with a paper system alongside individual computer systems for specific tasks. However, if there is a real dynamic task to be accomplished through simultaneous sharing of information to make various processes more efficient, then the data warehousing aspect comes into play. Many hospitals evolve their own data warehousing system, often on an ad hoc basis. But because of the traditional departmental aspects of hospitals, as well as the increased pressure on information technology (IT) departments, they are better advised, says Rempe, to go to a third-party source such as Iron Mountain. “We have the infrastructure so the hospital can purchase the functionality as it needs it and when it needs it,” he says. “This is less costly for the hospital to purchase its own storage system and try to do all the integration itself.” Initiate Systems, Inc., based in Chicago, is another third-party organization that provides customer data integration data warehousing for hospitals. There are a couple of approaches hospitals can take when it comes to data warehousing. A hospital can start with a complete system, or it can proceed on an ad hoc basis. Scott Schumacher, chief scientist at Initiate Systems, refers to the ad hoc approach as virtual data warehousing. Schumacher says, “I’m relatively agnostic. One approach is not necessarily better than the other.” He adds that if the reason for the connectivity of records is research, then the actual data warehousing is a much better choice. Because of all the data that is needed, research is harder to complete on a piecemeal basis. On the other hand, if the focus of the warehouse is patient safety, financial records and even certain departments, such as radiology, might be left out. Sometimes, as with the latter, a “pointer” might be utilized to show the viewer how to get to the radiology data. But the main data relating to patient care, including pharmaceutical data, should all be on the same network and available for immediate access. “Hospitals track records fairly well, but what they are not particularly good at is tracing encounter to encounter to encounter,” Schumacher says. “Hospitals have been aware for some time of the cases of injury or death caused by themselves, often in terms of adverse drug reactions. So there has been an increased pressure in this area for a data warehousing solution which delivers the full patient history to the physician, not just information generated during the recent encounter. This typically requires a patient matching algorithm. It’s very important for physicians to have complete information about a patient. And the pressure in this direction is now coming from doctors, who are obviously a very powerful force within a hospital. A leading hospital was recently forced to close down its test development program by the doctors, for it didn’t provide them with the total access to the electronic medical records that they need.” Schumacher estimates that 30% to 40% of hospitals are using some form of either virtual or actual data warehousing, with the implication that certain data banks, such as those relating to patient care, can be accessed in one place and can also be moved around by the doctor or other users. Administrators often see these IT initiatives as additional cost factors. However, Schumacher says, “the key to healthcare is providing high-quality care to the patients. Providing this care and minimizing mistakes is a cost saver in the long run.” Schumacher adds that scanning equipment has gotten much better, increasing the amount of visual along with text data relating to the patient. At the same time, storage systems have increased their capacity while decreasing their costs. These make bringing more patient information into the warehouse cost-effective. Another use for data warehousing, Schumacher says, is marketing. “I don’t see much of that now, but when I talk to CIOs [chief information officers], especially in urban areas, they say they would like to see where their patients are coming from, what they are being treated for, and what the competition is doing,” he says. For instance, a CIO would like to know if his or her facility should invest in a $100,000 machine or if the patient should be sent elsewhere for that service. “Every year healthcare costs go up, so knowing how to deliver services, how to keep costs down, how and how often customers are interacting with the facility, and where they live—all that sort of information impacts the bottom line,” says Schumacher. “So, I do see data warehousing for marketing costs coming.” John Quinn, a principal and healthcare consultant with Capgemini, sees a more immediate use for data warehousing in the financial realm in the area of management reports. A main problem, Quinn explains, is that hospitals are not typical capitalistic ventures in which costs, revenues, and profits can be determined in a fairly straightforward manner. Payments come in different forms of insurance, copayors, cap payments, and so on. “It’s very difficult for a hospital to determine its real costs,” Quinn says. “Many times, costs are figured out after the fact.” He says the data warehousing solution—and not necessarily an easy one—is to take various systems, such as accounts receivable, accounts payable to suppliers, and payroll, and to find out the actual costs, obvious and hidden, for the care of any particular patient. “Marrying them all together is always a problem, a big challenge,” Quinn says. “A lot of hospital work is done by volunteers. Though there’s no payment to these people, their work should be accurately estimated to give an accurate view of treatment when they might not be available.” Quinn says every hospital has some sort of decision-support system, even if working off a spreadsheet, which fits loosely into the definition of virtual data warehousing. But again, putting the information all together in a way that can yield meaningful results is difficult. The data gathering should be related to a specific goal, such as reducing costs to increase net revenue. He adds that in setting up the system, IT must be involved in getting the necessary data transmitted into the desired reports. And the system should also be amenable to users, whether it’s clinical- or business-oriented. Getting every bit of information included may not be either possible or necessary. “Depending on what your goals are, the 20/80 percent rule may be adequate,” says Quinn. (The 20/80 rule, formally known as Pareto’s Principle, states that a small number of catalysts are responsible for a major number of effects.) According to Quinn, there are three basic ways hospitals go about building their data warehousing outside of third parties. The first is those that have already begun integrating various systems on an ad hoc basis. “Here, it may take a relatively small amount of work and expense to get the rest of the data in and structure the reports you want,” says Quinn. The second is turning to vendors of large data warehousing systems. The problem here is that these are designed for a wide variety of industries and are not necessarily hospital-specific. “These can be customized, but generally that’s difficult, for it’s a bit of a trick to get them adapted for a hospital environment,” Quinn says. The third option is vendors who specialize in healthcare as a niche market. “This is by far the most common approach,” Quinn says. “There are some 15 to 20 of these, and they have varying strengths, often depending on age. Some had strong products in the ’80s but have kept the same technology, whereas some of the newer offerings have distinct advantages.” Premier Inc. is one of those data warehousing vendors that focuses on the healthcare industry. “Vendors are being challenged by the larger amounts of data being put into these warehouses and how they need to be analyzed in all sorts of different ways, with the information returned quickly,” says Gary Feierstein, Premier’s vice president of information technology. “Now the requirement is that data be analyzed within 30 to 60 days. If it takes up to a couple of years, the value tends to be lost.” Feierstein says there are two main reasons for electing to use data warehousing technology. The first is to benchmark best-practice procedures, whether operational or clinical, providing a standard for constant improvement. For example, it may be found that a particular physician tends to utilize procedures that are either relatively inefficient or cost-ineffective compared with the best-practice standard. Data warehousing also allows hospitals to compare themselves with other facilities in areas such as emergency department visits, number of incidents, amount of labor, costs, and success rates. “We’ve been fortunate in that we’ve been able to stay ahead of the curve and so have the technologies that can meet the increased demands,” Feierstein says. “We sell a product but have found that it’s not going to help unless the hospital utilizes it fully, so we bundle our product with consulting. We install the product, then train the users until they are up and running and are on the path to continual improvement. One way we differentiate ourselves is not by simply providing canned reports, but rather allowing users to go in and basically mine the data, to ask different questions to get what they want.” — Thomas G. Dolan is a medical/business writer based in the Pacific Northwest. |
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