MN-DAMA Feb 20031

Is Healthcare the Most Complex IT Industry ?

Skip Valusek Quality Engineer, Director Performance Improvement

Children’s Hospitals & ClinicsMinneapolis/St Paul

The content of this presentation and discussion is solely that of the presenter.

skip.valusek@childrenshc.org612 813-5876

MN-DAMA Feb 20032

Exercise: What Makes IT Complex ?

1. Identify three dimensions of complexity

2. Pick the dimension you feel is the most important contributor to IT complexity

MN-DAMA Feb 20033

Complexity Components

• • • • • • • • • • • •

• • • • • • • • • • • •

MN-DAMA Feb 20034

AGENDA

• Very Brief Review of IT Technical Dimensions of Complexity

• Brief discussion of “DSS: A Paradigm Addition”

• Inter-active discussion of business dimensions of complexity

MN-DAMA Feb 20035

Very brief: IT Technical Dimensions

• Interfacing/Networking requirements– Information security requirements– Bandwidth

• Database requirements– Structural fit

• Flat file• Hierarchical ?• Relational?• Object ?

– Standardizing definitions– Identifying acceptable values

• Application requirements– Breadth– Depth– Volatility

MN-DAMA Feb 20036

End-users as a dimension of complexity

• Number

• Types

• Range of End-User: – PC Maturity– Expectations

• Rate of change of all the above

MN-DAMA Feb 20037

Technology change

• Rate

• Impact on transaction processes

• Impact on decision processes

MN-DAMA Feb 20038

Information Management Premise

• The purpose of managing information and knowledge is to improve decision making capability.

• More effective information/knowledge management requires a paradigm

ADDITION for both IT and user communities.

MN-DAMA Feb 20039

Predominant Metaphors Used in Organizations:

• Machine

• Military Command & Control

The new, emerging metaphor of the decision paradigm:• Biological or Living Systems

(complex adaptive systems)

MN-DAMA Feb 200310

Decision-Making

• Decisions commit resources through

judgment and choice processes• There is process in decision-making:

• Opportunity/Problem Detection & Explanation

• Alternative Generation

• Analysis (value & probability judgments)

• Selection among alternatives

• Implementation

• Can we model this process?– Judgments (Value & Likelihood)– Choices

?

MN-DAMA Feb 200311

Decision Categories

• RESEARCH & ANALYSIS• ‘across’

• accounts, customers, patients, • channels, practices• markets, • periods, day of week, time of day

• Unstructured (little or no process) • Find key variables• Collaboration & sharing.• Design & Refine protocols/pathways

RETROSPECTIVE / ANALYTICALTACTICAL & STRATEGIC

DECISIONS

• ‘Quick Look’JUDGMENTS & CHOICES • ‘within’

• a PATIENT: view WHAM• a PROVIDER: rounding list• a DEPARTMENT: staff scheduling• a MARKET: assess event impacts

• Empower employees (within limits)• Semi-structured process• Apply protocols/pathways/guidelines

CONCURRENTCLINICAL & OPERATIONAL

DECISIONS

CURRENT

HISTORY

Demographic

DataWarehouse

“ “

“

“Source”Systems

MN-DAMA Feb 200312

Additional Bridges Required

USER’SDECISIONWORLD

OLAP AnalyticalDecision Processes

CURRENT

HITORYS

Demographic Operational/ClinicalDecision ProcessStoryboards

SYSTEMS/DATASYSTEMS/DATA

Warehouse(Oracle)

Quality Patient Safety

OB database

Complaints MediPac

Eclipsys (Sybase ?)

CVMicroMedical

RisKey (AREV)

Cactus (credentialing)

ADAC Lab database

(Fortran)

Ortho Database

Neuro database?OR Navicare

Pxyis

SurgiServerb-trieve

MICC database

CV Lab

Logician (MedicaLogic)(Oracle)

Picker (local)

Medica Claims

DISC

STAR(MUMPS)

Inpatient Pharmacy(STAR)

Radiology(STAR)

STARLab

OutpatientPharmacy

ORYX 6-digit coding

Sungard(Oracle)

Quality IndicatorsHDM(B-trieve)

EXTERNAL SOURCE SYSTEMS

Abaton(Oracle)

Medline

Micromedex(drug info)

MN Hospital Assoc

Allina KnowledgeQuest

USERSUSERS

Pharmacy

Patient Relations

External/RegulatoryRelations

Provider Relations

PayorRelations

Outpatient/Ambulatory

CV

Ortho

Neuro

ORED

OB/Womencare

Radiology Lab

BehavioralHealth

Oncology

Care-effectiveCost

Med Staff

IT MODELSIT MODELS

OLTP TransactionProcess(ERD; DFD)

MN-DAMA Feb 200313

Transition to Decision Support

TODAY

Detection: “What’s Going On?”

FUTURE

Explanation: “Why is it happening?”

“What’s the best action ?”

REPORTING

ANALYSIS

DATA

QUALITY

DATA

QUALITY

ANALYSIS

REPORTING

•Opportunity/Problem Detection & Explanation•Alternative Generation •Analysis (Cost/Benefit judgments) •Selection among alternatives•Implementation

MN-DAMA Feb 200314

Projects & Measures of the Business:

“FINAL”

Internal Measures External Measures

“PILOT” Project

• Start Small & Grow: The Decision Support Paradigm• Healthcare: PDSA Rapid Cycle model for change

MN-DAMA Feb 200315

Managing Evolutionary Design & Development

Time (weeks)

User Requirements Evolution

SystemEvolution

20 36 52 72 88 104 120

Mea

sure

Groupings

Time

Mea

sure

Groupings

Time

Mea

sure

Groupings

Time

Mea

sure

Groupings

Time

Mea

sure

Groupings

Time

Mea

sure

Groupings

Time

MN-DAMA Feb 200316

Managing Evolutionary Design & Development:Obtaining & Sustaining Business Sponsorship

• Instill a sense of urgency (level of pain)

– A critical success factor of organizational change

• Manage expectations

• Provide and retain funding

• Recruit and retain skills

MN-DAMA Feb 200317

AGENDA

• Very Brief Review of IT Technical Dimensions of Complexity

• Brief discussion of “DSS: A Paradigm Addition”

• Inter-active discussion of business dimensions of complexity

MN-DAMA Feb 200318

IT Complexity Framework: Assess Business Processes in Four Categories

FinancialOperationalRegulatoryClinical

FinancialOperationalRegulatoryClinical

FinancialOperationalRegulatoryClinical

FinancialOperationalRegulatoryClinical

Transaction (I-P-O)

Real-Time/Operational

Retrospective/Analytical

Decision (Judgments & Choices)

MN-DAMA Feb 200319

Real-time “Transaction”: Financial Billing complexity

Providers

Physician(s)Practice(s)

Hospital &Staff

“Coding” &Appropriate

bills prepared

Payors

DRGs, CPT

Paymentmade

• Payors contract(s)• Individual

time

Customer(patient)presents

Servicesprovided

Discrepanciesresolved

MN-DAMA Feb 200320

Real-time decision complexity: Safety

• Operational/Clinical– Number of front-line employees with decision

responsibility– Number of judgment and choice processes for each participant– Number of processes requiring communication– Number of potential failure points

MN-DAMA Feb 200321

One sample judgment process: Right “customer” ? Complete record ?

• What are the customer expectations regarding a “complete” knowledge of their relationship ?

• Difficulty creating a complete customer record for accurate customer decisions.

• Who has the master patient record?

MN-DAMA Feb 200322

Real time decision: patient placement/flow

Scheduling & Admissions Forecast

ReferringPhysicians

Consulting & Admitting Physicians

ER

Children’sPhysicianNetwork Physician Referral

Telephone Line

OR

External Events

Nurse Staffing

HousekeepingStaffing

DischargeForecast & Status

Homecare

AncillaryServices

Other HospitalStatus

Sister HospitalStatus

InterpreterServices

BEDS

Infection Control

Short Stay

?

Family Needs

Historical Forecast

Isolation Beds

SUPPLYDEMAND

ER

MN-DAMA Feb 200323

Real-time decision: Financial

• EMTALA doesn’t allow financial considerations to enter the initial real-time decision process. Those who “present” to the ER must be assessed regardless of ability to pay.

• Forces the problem to the retrospective domain

MN-DAMA Feb 200324

Real-time decision complexity: Satisfaction

• What are “customer” dis-satisfiers?– Parking– Food– Delays in treatment; waiting time– Double rooms– Staffing– Communication– Poor transitions– Inability to reach consulting physician– Who’s in charge?

MN-DAMA Feb 200325

Retrospective Decision: Dimensions for analysis

Patient DRG orAPR ICD-9

CP

T-4P

ractice &P

rovider

Employer

Plans/

Payors

Fac

ility

Dep

artm

ent/

Uni

t

Date/TimeDay

Example attributes of importance:

• Age appropriate

• Culturally appropriate (44 languages/cultures)

LOS

ChargesPatientDays

Census

MedicationUsage

BloodUsage

Delays

Accuity/Severity

Case Mix

ClinicalOutcomes

MN-DAMA Feb 200326

Measurement of Quality/Evaluation of Success

• Balanced Scorecard Components– Safety – Access– Finance– Experience

• Stakeholders– Patients– Families– Physicians– Nurses– Ancillary Services– Payers– Regulators

MN-DAMA Feb 200327

Retrospective Analysis: Transaction

• Safety– Labeling of specimens– Labeling of medications– Waiting time

• Access– Length of stay– Time to turn a room– Waiting time

• Experience– Billing – Waiting time

MN-DAMA Feb 200328

Difficulty properly attributing provider/servicer

• Team of service vs individual• Practices (“coverage”)• Roles

– PCP– Attending– Procedure– Consult– Resident– Team services

MN-DAMA Feb 200329

Retrospective Analysis: Relationships

Children’sServices

& Provider Network

CommunityEfforts &

Action Groups

LocalState

NationalGovernments

Schools

Families

PhysicianGroups

LocalState

Public Health

Managed CarePayers

Hospitals

Community-basedadvocacy groups

Social ServiceProvidersMHHP,

NACHRI, AAP,

MCHP, CDF

Clinics

Employers

MN-DAMA Feb 200330

Regulatory/Compliance/Accreditation (Number of regulators & Information intensity)

HOSPITALS

Administrators OfficeHCFA

Health Care FInancingAdministration

Federal CircuitCourts

Supreme Court

Congress

PRRB

DepartmentalAppeals

OIG

MIPS

State Survey &Survey

Certification

Regional Offices Intermediaries Carriers PRO's

DMERC

Regional HomeHealth Intermediaries

JCAHO

State HealthBoards

StateMedicaid

HHS/NIOSH

HHS/HRSA

StateLicensure

FDA

DOT

OSHA

Labor/JusticeADA

DOL/Employment

NRC

DOJ

State Medical Boards

OPO'S

State & LocalGovernments

SEC IRS EPA FTC FCC FBI

HIPAA

Leapfrog

CDC NCQACARF

EMTALA

CLAS

HHS/OCR

HHS/OMH

MN-DAMA Feb 200331

Rate of content knowledge creationImpact on real-time and retrospective decisions

• Clinical guidelines• CPOE

• Clinical guidelines• CPOE

Transaction (I-P-O)

Real-Time/Operational

Retrospective/Analytical

Decision (Judgments & Choices)

MN-DAMA Feb 200332

Review of Healthcare Complexity: Change Process

Transaction(I-P-O)

Decision Intensity

(Judgments & Choices)

Ability to achieveagreement(across & withinstakeholdergroups)

Real-Time/Operational

Retrospective/Analytical