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Building a Warehouse

July 23, 2008
by Daphne Lawrence
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CIOs are finding that while a warehouse is the end game, data marts make the ride more productive

Patricia salem

Patricia Salem

Dashboards are a hot topic on CIOs' current to-do list — hospitals either want them or are working on developing them. Why? The need for immediately actionable data is more intense than ever, and growing daily, as hospital and health system executives seek to analyze and optimize operational performance in real-time. But that's easier said than done, as hospitals can have hundreds of data silos. Before an IT team can even get to the dashboard, it's got to do a lot of plumbing. Or, as Patricia Salem, vice president of Healthcare Planning and Business Intelligence at Golden Consulting (Bloomfield, Conn.) puts it, “You've got to get the information under control.”

Why the sudden push? With pay-for-performance initiatives expanding, hospitals are scrambling for tools to put information into useful, actionable formats. Naturally, the pressure falls on CIOs and their IT teams. “Hospitals are going crazy,” says Salem. “They're trying to run reports, respond to users for reports, and business users are sending report requests to IT. IT can't keep up.”

Mike davis

Mike Davis

Increased demand is also arising out of the rapid growth of the EMR, and the new availability of information in electronic format. There's also the manual problem of printing, copying and mailing reports.

So if dashboards are in such demand, why the slow adoption? The general problem has been the lack of data warehouses in hospitals. But smart CIOs are beginning to see that dashboards can be utilized even without them, and they're experimenting with a variety of dashboard solutions, either homegrown or Web-based.

Dashboards — in the form of executive information systems (EIS) — go back around 15 years; most early versions focused on financial performance. “The intent was to create a high level overview of key performances indicators: adjusted patient days and discharges, readmissions within 24 hours, and all the things that have an impact on operations or reimbursements,” says Mike Davis, vice president of Chicago-based HIMSS Analytics. Many hospitals began creating Web-based dashboards to look at specific data elements or reports created in other systems. “You can do that,” says Davis. “The issue is you're only looking at data from one environment.”

The dashboards were also useful in aligning the strategic goals of an organization on a monthly or quarterly basis, often to report to the board — a “how are we doing” overview. Those often included indicators like patient and employee satisfaction data.

The challenge was information aggregation from disparate sources. “Keeping these environments in sync was problematic, with a lot of overhead,” says Davis. “It was an interoperability nightmare. And the data might not have been as accurate as (people) thought it was.”

Most agree that a data repository is the answer. “You can do it where you map directly into applications,” says Davis, “but all you basically get are the reports from those applications. And a lot of this stuff is going to be retrospective.”

That's not always the worst thing in the world. According to Davis, retrospective information is usually good enough for the C-suite. “When I come in at 8 in the morning, I want to see a snapshot of what happened yesterday,” he says.

Today, most hospitals are still not sophisticated enough to correlate financial and clinical information, especially in real time. The exceptions are the larger academic and community hospitals and multi-hospital integrated systems that have developed the one aforementioned tool that makes it possible — the data warehouse.

Still, progress is being made industry-wide, observers note. “A lot of hospitals are undergoing huge data warehousing projects,” says Salem. “Many hospitals have the long-term vision of dashboards, but it takes years to get the process in place, get the warehouse together and internally work with business users in different departments to find out the key reporting metrics and data sources. This technology has been very expensive, and the community medical centers couldn't even look at it due to the cost.”

So in the absence of a data warehouse, what can a CIO do in the interim?

Rick schooner

Rick Schooler

The good news, says Davis, is that Web tools with reporting services can sometimes be used in lieu of a true data warehouse. He says the newer business intelligence products do a better job of capturing information from diverse environments. “When you look at self-developed (solutions), that's what people are doing,” he says. “These are very focused data marts that gather and capture information to put into whatever algorithms you want to track key-performance indicators. Visually, they're very appealing.”

That's what Rick Schooler, CIO of Orlando Health (Orlando, Fla.) is doing; although, he says, a true business intelligence platform is definitely part of his long-term strategic plan. His tactics might sound familiar to many CIOs. “We do not yet have what we would consider an enterprise data warehouse,” he says. “We have what I would call data marts that are more focused on particular types of information, or they're a drill-down tool.”

Schooler uses McKesson (Alpharetta, Ga.) Horizon Business Inside as a tool that gives him up to 20 levels of drill-down on census, volume, financial reporting, general administrative or business statistics. “It's primarily reporting information that is retrospective,” he says. Orlando carried out in-house development too, using Microsoft's visual studio and .NET platform tools to build core measures reporting.

Schooler also uses Emeryville, Calif.-based MedeFinance, whose RCM tool feeds directly out of his registration and patient accounting systems and, he says, has significant drill down abilities. “We're moving to real-time updating of these dashboards.” He also uses MedAssets' (Tupelo, Miss.) RCM and supply chain optimization tools. “Those are fed by our respective systems; they're actually ASP-based (application service provider),” he says.

One question that's often asked is who has ownership of the dashboards. Is it IT? Finance? Decision support? The answer seems to be evolving. “Often, IT is putting these dashboards together, so right now it's IT for the initial setup,” says Salem. “Going forward, the users will be trained and able to order up dashboards for any metrics they want. The key is setting up the universes and mapping all the data and integrating it. Once it's said and done, it's easy.”

For many years, John Stanley, CIO of Riverside Health System, Newport News, Va., ran an executive information system for his management team and board, but has lately begun to drill down into deeper layers of data. “We had started with our main indicators, about 26-27 of them. People said, ‘This is doing very well, but we need to blow out the quality area and have a sub-scorecard that gives more depth and more indicators.’” Today, Stanley says he can pinpoint turnover down to the very departments, and patient satisfaction down to the nursing units.

John stanley

John Stanley

Stanley is using SciHealth (Atlanta) for his scorecard. “The scorecard product has mapping utilities that say, ‘This is what I'm getting in column one, two, three and four.’ It's like a giant spreadsheet.” His system-support department manages the dashboard. “They're not IT professionals, they're just using that file and mapping it,” he says. “We may have to write a report to get information out, and in some cases we do some calculations, but it's not that technical.”

How long did it take to set that up? “Our first scorecard was at the top level,” he says. “It shows us what we're doing (over the entire) health system,” explained Stanley. “It took about three months to introduce the software, and do the mapping. We have 150 indicators now. Peer pressure works.” Afterthe vendor trained the staff and the mapping was rolled out to 500 leaders and managers, Stanley brought up 300 doctors and their office manager.

And what about the doctors? Especially when it comes to pay-for-performance, most say bringing physicians on-board, on any level, is the hardest part. “We're beginning to have our quality people introduce dashboards to physician leadership,” says Schooner. “And you have to be very careful because the data absolutely has to be rock solid and beyond reproach.”

At Riverside, Stanley's doctors have found that using the dashboards helps them to improve core clinical outcomes measures. “All the doctors can go to the scorecard and click on the highest level of practice and see if they're meeting all their indicators on diabetes. There's a sense of outcomes.” He says they can then click on the practice and see that four physicians are doing fine, and the fifth might be behind on his screenings. Then they click on the physician to see what measures they've been tracking — and click on the measure. “And what we love is that it's all right there in front of them and they don't have to hop from system to system,” says Stanley.

That type of application remains a standout in the industry. So for a CIO just beginning to walk down the dashboard path, what advice is out there?

Many say start at the top. “A lot of hospitals develop these scorecards for a particular reason and now they're all struggling to get executive buy in,” says Stanley. “Our executives drive our bus. If all you want the scorecard to do is measure your improvement in the ED, it's going to be limited to that area. We started at the top,” he explains.

Salem suggests faculties start with an organizational strategic plan. “A lot of hospitals have already bought into this and adopted a balanced scorecard and are running around with it on an Excel spreadsheet — it takes 50 analysts a month to put it together, and it's color coded. It's static, with no trends, no drill down.” But, she says, don't abandon it. “Embrace the strategy and then align the strategy throughout the organization. Start at the top and roll it down. Every department should have it, and have the same or similar goals.”

Schooler recommends CIOs ask themselves two major questions. “First and foremost, do I have the source data identified and available? The requisite technologies may not be in place, and that's a bigger deal than a lot of people think. Second, you have to understand the priority areas for your organization because you can go off into every corner and start building a dashboard.”

And when it comes to staffing, Schooler (who has a CMIO at Orlando Health) believes strongly in the role of clinical informaticists. “If I could say anything to anybody getting ready to automate, you've got to have those informatics people,” he says. “Because once you get those systems up, they're going to be doing the clinical data mining and changing the way you deliver care with it.” He believes the IT department alone is not going to be successful. “You've got to have that informatics team, and that is a key step when you move into clinical-data managing and clinical dashboarding.”

Another common dashboard issue is making sure any data comparisons are apples-to-apples. Riverside's challenge was its three separate EDs. The organization wanted to do some measures with the goal of reducing wait times, but all three kept track of time a little differently. For example, one was measuring time when a patient first walked in the door, and another when the patient was first logged in. “You have to agree on definitions,” he says.

Accountability is another key factor — if no one is accountable, who is responsible? “We have names attached to each area,” Stanley says. “It's great to look at your average length of stay, but if nobody's accountable for it, why?”

So what lies ahead? Or, for CIOs who have already begun using scorecards, what's next?

“The next step we've got to get to with core measures reporting, is to capture that information in more of a surveillance real-time mode,” says Schooler. “To be able to say to the care provider, ‘You've got 10 minutes or we're going to miss the core measure on this chest pain patient.’ That's the kind of intelligence we're trying to get to, and that will require sophisticated warehousing tools,” he says.

At Orlando, Schooler says he's building the extracting platform out of Eclipsys' Sunrise suite (Boca Raton, Fla.). “We're building it piece by piece.” However, he says having the warehouse isn't the point, rather the key question is what kinds of marts are in that warehouse that line up with service priorities and information needs. One of those needs could be extracting information from the EMRs across the hospitals.

“In the future,” agrees Davis, “people will need to figure out what clinical and financial data they want to correlate to have the biggest impact on their operation.” He says that right now, there's a lot of standard financial information and that's what people are tracking. “The next step in taking information to the next level is to break it down and compare it and contrast it with clinical information. That's what the Brighams and Intermountains and Mayos have.” He believes more people will move in this direction within the next few years, especially as compensation based on quality becomes more prevalent.

“You don't really get into data mining until you get into data warehousing,” says Schooler. He says that from an enterprise perspective, IT is going to have to supply departmental reporting solutions that may be dashboards, while hospitals will still have the corporate dashboard. “That's kind of a roll-up tool, in my opinion,” he says. “When you start moving into true warehousing, you introduce the ability to do slicing and dicing as well as handle massive volumes of data. And that's where we have to go. Warehousing is the end game.”

Healthcare Informatics 2008 August;25(8):62-66

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