Transcript Is Healthcare the Most Complex IT Industry ?

Is Healthcare the Most Complex IT Industry ?
Skip Valusek
Quality Engineer, Director Performance Improvement
Children’s Hospitals & Clinics
Minneapolis/St Paul
The content of this presentation and discussion
is solely that of the presenter.
[email protected]
612 813-5876
MN-DAMA Feb 2003
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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
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Complexity Components
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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
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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
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End-users as a dimension of complexity
• Number
• Types
• Range of End-User:
– PC Maturity
– Expectations
• Rate of change of all the above
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Technology change
• Rate
• Impact on transaction processes
• Impact on decision processes
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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.
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Predominant Metaphors Used in Organizations:
• Machine
• Military Command & Control
The new, emerging metaphor of the decision paradigm:
• Biological or Living Systems
(complex adaptive systems)
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Decision-Making
• Decisions commit resources through
judgment and choice processes
• There is process in decision-making:
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Opportunity/Problem Detection & Explanation
Alternative Generation
Analysis (value & probability judgments)
Selection among alternatives
Implementation
?
Can we model this process?
– Judgments (Value & Likelihood)
– Choices
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Decision Categories
RETROSPECTIVE / ANALYTICAL
TACTICAL & STRATEGIC
DECISIONS
CONCURRENT
CLINICAL & OPERATIONAL
DECISIONS
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Data
Warehouse
• RESEARCH & ANALYSIS
• ‘across’
• accounts, customers, patients,
• channels, practices
• markets,
• periods, day of week, time of day
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Unstructured (little or no process)
Find key variables
Collaboration & sharing.
Design & Refine protocols/pathways
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Demographic
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“Source”
Systems
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Y
• ‘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
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Additional Bridges Required
SYSTEMS/DATA
USERS
Pharmacy Radiology
Lab
ADAC
Lab database
(Fortran)
OB
database
Neuro
database?
OR Navicare
External/Regulatory
Relations
Oncology
OB/
Womencare
Med Staff
Ortho
Care-effective
Cost
Neuro
SurgiServer
b-trieve
CV Lab
MICC
database
CV
MicroMedical
Ortho
Database
Cactus
(credentialing)
Quality
Picker (local)
Patient Safety
RisKey
Complaints
(AREV)
Provider
Relations
CV
Behavioral
Health
ED
Payor
Relations
OR
Outpatient/
Ambulatory
ORYX
Inpatient Pharmacy
6-digit coding
(STAR)
STAR Radiology Outpatient Pxyis Quality Indicators
HDM
Sungard (B-trieve)
Lab
(STAR) Pharmacy
(Oracle)
STAR
Eclipsys
(MUMPS)
(Sybase ?)
EXTERNAL SOURCE SYSTEMS
Medline MN Hospital Assoc
Abaton
Micromedex
(Oracle)
(drug info)
Patient
Relations
Allina KnowledgeQuest
Logician (MedicaLogic)
(Oracle)
DISC
MediPac
Warehouse
(Oracle)
Medica Claims
IT MODELS
OLTP
Transaction
Process
(ERD; DFD)
OLAP Analytical
Decision Processes
USER’S
DECISION
WORLD
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Demographic
U
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Operational/Clinical
Decision Process
Storyboards
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Transition to Decision Support
•Opportunity/Problem Detection & Explanation
•Alternative Generation
•Analysis (Cost/Benefit judgments)
•Selection among alternatives
•Implementation
FUTURE
TODAY
Detection: “What’s Going On?”
Explanation: “Why is it happening?”
“What’s the best action ?”
ANALYSIS
ANALYSIS
REPORTING
REPORTING
DATA
QUALITY
DATA
QUALITY
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Projects & Measures of the Business:
• Start Small & Grow: The Decision Support Paradigm
• Healthcare: PDSA Rapid Cycle model for change
“PILOT” Project
“FINAL”
Internal Measures
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External Measures
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Groupings
Measure
Groupings
Measure
Measure
Measure
Managing Evolutionary Design & Development
Groupings
Groupings
System
Evolution
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36
52
72
88
104
120
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Time (weeks)
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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
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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
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IT Complexity Framework:
Assess Business Processes in Four Categories
Transaction
(I-P-O)
Real-Time/
Operational
Retrospective/
Analytical
Decision
(Judgments & Choices)
Financial
Operational
Regulatory
Clinical
Financial
Operational
Regulatory
Clinical
Financial
Operational
Regulatory
Clinical
Financial
Operational
Regulatory
Clinical
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Real-time “Transaction”:
Financial Billing complexity
Providers
Physician(s) Hospital &
Practice(s)
Staff
Customer
(patient)
presents
Discrepancies
resolved
Services
provided
“Coding” &
Appropriate
bills prepared
DRGs, CPT
time
Payment
made
• Payors contract(s)
• Individual
Payors
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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
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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?
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Real time decision: patient placement/flow
DEMAND
SUPPLY
Infection Control
Historical
Forecast
External
Events
Scheduling &
Admissions Forecast
Nurse Staffing
?
ER
Short
Stay
Family Needs
Referring
Physicians
Children’s
Physician
Network
Housekeeping
Staffing
OR
Sister Hospital
Status
Physician Referral
Telephone Line
Interpreter
Services
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Homecare
Isolation
Beds
BEDS
Consulting &
Admitting Physicians
Ancillary
Services
ER
Discharge
Forecast
& Status
Other Hospital
Status
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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
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Real-time decision complexity: Satisfaction
• What are “customer” dis-satisfiers?
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Parking
Food
Delays in treatment; waiting time
Double rooms
Staffing
Communication
Poor transitions
Inability to reach consulting physician
Who’s in charge?
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Retrospective Decision: Dimensions for analysis
Patient
Date/Time
Day
Accuity/
Severity
Case Mix
LOS
Charges
Patient
Days
Clinical
Outcomes
Census
Medication Blood
Delays
Usage
Usage
Example attributes of importance:
• Age appropriate
• Culturally appropriate (44 languages/cultures)
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Measurement of Quality/Evaluation of Success
• Balanced Scorecard Components
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Safety
Access
Finance
Experience
• Stakeholders
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Patients
Families
Physicians
Nurses
Ancillary Services
Payers
Regulators
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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
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Difficulty properly attributing provider/servicer
• Team of service vs individual
• Practices (“coverage”)
• Roles
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PCP
Attending
Procedure
Consult
Resident
Team services
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Retrospective Analysis: Relationships
Schools
Community
Efforts &
Action Groups
Community-based
advocacy groups
Children’s
Services
&
Provider
Network
Hospitals
Local
Families
Employers
State
National
Governments
MHHP,
NACHRI,
Local
AAP,
State
MCHP,
Public Health
CDF
Physician
Groups
Clinics
Social Service
Providers
Managed Care
Payers
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Regulatory/Compliance/Accreditation
(Number of regulators & Information intensity)
Supreme Court
Federal Circuit
Courts
Departmental
Appeals
Congress
Administrators Office
HCFA
Health Care FInancing
Administration
OIG
MIPS
State Survey &
Survey
Certification
PRRB
Regional Offices
Intermediaries
Carriers
PRO's
JCAHO
DMERC
HIPAA
State Health
Boards
Regional Home
Health Intermediaries
State
Medicaid
State & Local
Governments
State Medical
Boards
EMTALA
HHS/NIOSH
Leapfrog
HHS/OMH
HHS/HRSA
HOSPITALS
HHS/OCR
State
Licensure
CLAS
FDA
DOT
OSHA
Labor/Justice
ADA
DOL/
Employment
OPO'S
DOJ
NRC
SEC
IRS
EPA
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FTC
CARF
CDC
FCC
NCQA
FBI
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Rate of content knowledge creation
Impact on real-time and retrospective decisions
Transaction
(I-P-O)
Real-Time/
Operational
Decision
(Judgments & Choices)
• Clinical guidelines
• CPOE
• Clinical guidelines
• CPOE
Retrospective/
Analytical
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Review of Healthcare Complexity: Change Process
Real-Time/
Operational
Ability to
achieve
agreement
(across &
within
stakeholder
groups)
Retrospective/
Analytical
Transaction
(I-P-O)
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Decision Intensity
(Judgments & Choices)
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