Recombinant is based on the east coast, which is unfortunate for us as the folks in Hawaii never called us about their new statewide data warehouse. Nonetheless, they are deploying a system that is focused on both population health and management of infectious diseases. Let it be known that Recombinant is always available with useful expertise and technology for statewide implementations--especially when it involves on-site work in Maui or any other decent surfing spot!

The interesting part of the Hawaii warehouse project is the alert and monitoring system that manages the spread of infectious diseases. This is a major problem in areas with high volumes of tourism, and a great example of why a government needs to review the unique economic and social structure of their state when building a centralized healthcare data warehouse.

Hopefully other states and large metropolitan areas that are timid about the notion of a statewide initiative will consider Hawaii as a successful reference point. Progress can be made on the political, competitive, and technical fronts that ultimately produce collaborations that are in the best interest of every patient's health and safety.

Dan Housman
Managing Director, Analytical Applications

Labels: Data Warehousing, Patient Safety

The article “EHR interface costs likely to plummet” written by Mary Mosquera, references statements made by John Halamka from a recent Healthcare Information Technology Standards Panel (HITSP) board meeting—the cost to interface EHR applications will drop from $20-30K per implementation to $5-6K based on standards increasing in interoperability.

I am not certain where the original pricing came from, but it is good news since price is one of the major barriers (outside of competitive issues) that stand in the way of establishing interfaces between health applications and systems.

Cost is a driving factor for the use of interoperability standards within clinical intelligence and population decision support initiatives. Recombinant is using components such as continuity of care document (CCD) standards as a method to create analytics capable of separating patients into risk groups using decision support logic.

My hope is that things remain open. As the price to interface through standards diminishes, it should become easier to implement standardized decision support at an individual or population-level, while remaining consistent.

Dan Housman
Managing Director, Analytical Applications

Labels: Clinical Intelligence

Government Health IT magazine recently published “The comparative effectiveness rally”, a great write-up by Phil Carey that explains comparative effectiveness research (CER).

The article includes interesting details from Dr. Brent James, executive director of Intermountain Healthcare’s Institute for Healthcare Delivery Research. He discussed his “Help Two” decision support system implementation as well as the Microsoft Amalga platform.

The Cochrane Collaboration was mentioned as an international, not-for-profit that documents comparative effectiveness. This was the first time I had heard of the organization, and it may prove to be a useful resource. One such example is their report on Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Unfortunately, the Cochrane library is not a public resource in the United States, but at least it exists and is being maintained through some financial model. From a software standpoint, the next steps for the Cochrane reports should include structured data sets in XML so that the reports can be analyzed and parsed into components for providers and decision support systems. Coding CER data is critical to its availability both at the point of care and when analyzing a population.

Another article worth mentioning in the same issue of Government Health IT magazine is “Medical analytics in war” by Peter Buxbaum. It discusses the importance of integrating population views through GIS systems to monitor outbreaks such as influenza within the theatre of battle.

“The U.S. military’s Medical Situational Awareness in Theater (MSAT) project, a portal application, is being designed to allow users to graphically view potential health threats to troops and to support decision making on the location of military medical units. MSAT will use Web services to allow commanders access to multiple databases and to generate graphical displays that turn raw data into actionable medical intelligence.”

The military frequently relocates troops, therefore it is critical to track location-based views. They are also focused on using Java standards to ensure data is available in component form.

Dan Housman
Managing Director, Analytical Applications

Labels: CER

The Business Times recently published the article “Technology and the fight against epidemics” by Suganthi Shivkumar. It is quite topical about the use of data warehousing and real-time messaging to monitor pandemics. An example in the article mentions the use of Informatica in Hong Kong to track the SARS epidemic.

With the upcoming H1N1 season fast approaching, it would be helpful if tools such as BioSense from the Centers for Disease Control and Prevention (CDC) had greater adoption. It would also help if local areas effectively leveraged EMRs and related infrastructure to help monitor and contain major pandemic risks.

It is possible that some organizations will launch new data warehouses specifically to fight pandemics; however it is more likely to be an offshoot from existing HIT investments. The financial model is complicated in a world where healthcare networks are independent of each other. That challenge is in the hands of the CDC to figure out.

Dan Housman
Managing Director, Analytical Applications

Labels: Data Warehousing

Steve Beller wrote the blog post “A Novel Way to Exchange Patient Health Information”, an interesting take on the NHIN, HIE, and research data warehousing world. It is further evidence of the coming convergence between HIE functions and healthcare data warehousing.

I prefer the decentralized peer-to-peer (P2P) thinking of the proposed solution as well as the simplicity of using Microsoft Office as a platform to share continuity of care document (CCD) messages between physicians. P2P is now infamous from Napster, and is an ideal way to exchange content without central hubs or repositories because it scales quickly and quietly by participants. The general idea of an HIE system involves P2P data exchange, but most architectures of today utilize big hubs.

The Microsoft Office-style exchange may work best for small practices, but not for large integrated health networks. EMR implementations such as EPIC and heterogeneous application systems across hospitals and outpatient facilities require centralized interface engines and CCD factories to consolidate interoperability.

A new twist in the development of a national patient identifier is the use of biometrics. This would avoid reliance on patient reported information which is often inconsistent and the cause of privacy issues. Although I personally like the idea, patient privacy folks may not be pleased with the notion of each office keeping a biometric imprint of their patients with the intention of sharing data.

The thought of universal biometrics reminds me of the movie Gattaca. I find it difficult to imagine every hospital and clinic registration system adding a fingerprint swipe or retinal scan to their hardware and software infrastructure. However, it is a clever idea to address the daunting challenge of uniquely identifying patients amongst a few hundred million people before providing medical facts.

I like the idea of adding de-identified feeds at a patient-level into the mix of the NHIN/HIE/RHIO frameworks for the purpose of public health and research. This is the first time I’ve heard of that idea and it might work for some applications. It may only scale for certain applications, because a warehouse is needed to query complex questions such as cohort size estimations. That being said, ePCRN doesn’t differ much from this approach.

Thanks for the thoughtful posting!

Dan Housman
Managing Director, Analytical Applications

Labels: Biometrics, Data Warehousing, Privacy

I had the pleasure to attend the PHIN conference in Atlanta last month. PHIN refers to the Public Health Informatics Network, a Centers for Disease Control and Prevention (CDC) initiative to improve the exchange of health data.

Recombinant was somewhat of a duck out of water in regards to public health because our focus revolves around clinical research and quality reporting through data warehousing. However, there were quite a few conversations where public health considered themselves uninvited to the table where data was being served.

Our knowledge about i2b2 and the capabilities of clinical systems for data management at hospitals led to some lively discussions and a handful of new opportunities. For example, the CDC has struggled to connect with chronic diseases and i2b2 would be an ideal way to connect to healthcare delivery networks with data management strategies around conditions such as coronary artery disease (CAD), hypertension, diabetes, and chronic obstructive pulmonary disease (COPD).

I met some vendors of interest that intersect with the clinical data warehousing world. A company in the Boston area called Diagnosis One has invested in developing a service including thousands of validated clinical decision support rules. We discussed combining their rule sets with the content that gets extracted and loaded into the Recombinant Data Trust. If anyone is interested in combining both a data warehouse and a privately maintained decision support rule library that is curated by physicians, give me a holler and we will pull together a collaboration with the folks at Diagnosis One!

Another vendor, Trizano, developed an open source public health application that could be a powerful tool linked with a data repository to handle the workflows for public health issues. Given that they focus on the beekeeper model like Pentaho, their licensing model should be compatible with research frameworks such as i2b2. Trizano’s tools might be another key application to drive value out of existing data sets.

The drive for meaningful use has also pushed a lot of interest in HIEs, thus these sorts of tools were well-represented at the conference. I was pleased to encounter the booths focused on IHE-HIE systems. The exhibitors clearly conveyed the message that an HIE doesn't ensure the sort of interoperability that is typically suggested. To ensure one will scale to a national level like an NHIN, the HIE must be implemented to satisfy IHE standards. Among the frustrating and somewhat odd outcomes from the rushed drive toward meaningful use by healthcare systems, is that many HIEs may never be interoperable because even the integration systems have put barriers in front of interoperability.

Based on the PHIN tour of HIE technology, it is now my preference to see more IHE-based HIEs. The Europeans and Canadians are rapidly adopting IHE, but in the United States we haven't wholeheartedly engaged in the standards and efforts at the healthcare-network level. Perhaps it isn't too late for national legislation or state initiatives to include requirements that satisfy international standards.

Dan Housman
Managing Director, Analytical Applications

Labels: Data Warehousing, i2b2