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The Intermediary
An exciting promise of business intelligence lies in its use to measure an organization's performance not just on the balance sheet, but within operational processes. Though many organizations are just discovering the need for better process management, every business can relate to the value of applying key performance indicators to discover resources that have been over-allocated, or bottlenecks that decrease productivity.
Not just products but services can benefit from data-sensitive process documentation, even in very dynamic settings. Take the example of a hospital emergency room, where an uncertain number of patients in varying conditions enter, wait, are treated and processed within an environment of harried and limited resources. The way in which such settings are managed and measured has everything to do with the health of the patient and the success of the organization.
Proving a Point
Jonathan Rothman has been known to lurk in emergency department corridors, clipboard in hand, following doctors and asking questions. Rothman isn't a doctor, but his father and brother are, and his sister-in-law has run emergency departments. Rothman parlayed his familial calling and a MBA in risk management into his current role, director of data management at Emergency Medical Associates. EMA is a physician-owned organization of about 250 M.D.s who operate three managed care facilities and 19 emergency departments for hospitals in New York and New Jersey. Hired as manager for a data warehouse project, Rothman was hopeful he'd do more than fiddle with databases and ETL tools, which is just what happened. "I was lucky enough to have a physician champion at EMA, a practicing doctor who had some pretty specific ideas. He figured we had all this great data and we should do something with it beyond research."
The goal would be to relate working processes with operational data pulled from hospital information systems, billing systems and clinical documents in order to create some definitive intelligence about performance. With the help of analytics, this could give EMA hospital clients hard numbers on all-important customer satisfaction. Separately, emergency department administrators would be given scorecards and dashboards to internally measure the performance of departments and individuals working in each hospital.
The exercise was actually a requirement because of ongoing strains placed on EMA by HMOs with fixed or decreasing reimbursements, and rising medical and liability costs. Emergency departments in particular are centralized targets for contract renegotiation, and unlike clinical offices, cannot turn away patients for lack of coverage. These constraints have limited assets for patient care and effectively frozen income for many of EMA's practicing physicians. "Our goal is to maintain," says Dr. Chris Freer, chairman of the department of emergency medicine at St. Barnabas Hospital in Livingston, NJ. "Some people here will tell you they're making the same income they were 15 years ago with no cost of living increase."
EMA cannot control HMO reimbursements, but it can control the efficiency of its organization. First, process documentation was needed to exactly determine how EMA went about its business. (See Fig. 1.) "I flowed the process by watching patients move through registration into triage, into a room," Rothman says. "I looked at the source systems used and came to understand how data flows from a hospital's registration and lab systems into our tracking system. I sat down with the billing folks and asked questions, how they load and move data and what happens with the chart."
Figure 1: ED Process Flow and Chokepoints
Having identified chokepoints in departmental processes, KPIs were identified and segmented by financial performance, (dollars in, expenses out), and customer satisfaction (waiting time, doctor attentiveness, overall satisfaction etc.). It's not something that could have been accomplished behind a desk. "I felt early on the only way I could develop credibility was by forming partnerships," Rothman says. "Once you establish credibility with a doctor or a person in HR, they have a tendency to give you a little more leeway with the development process." Working at the front lines would also bring some sensitivity and offset fears that the process drive was solely about increasing individual workloads or automating jobs out of existence.
The partnering approach brought forth insights from doctors who were interested in EMA's financial performance and how it balanced against the customer experience. "In terms of patient satisfaction, we had a belief that the front end of the process is the important end," says Dr. Raymond Iannaccone, director of the emergency department at Hudson Valley Hospital Center in Courtland Valley New York. "Saving 10 minutes getting the patient from the waiting room to the doctor is more important than saving 10 minutes after they have been evaluated or are waiting to be discharged." Customer satisfaction goes straight back to client satisfaction, which gave EMA a more empirical way of demonstrating the quality and value of its services.
Rothman found a correlation between time to treatment and increased satisfaction scores. That provided hospital administration with a proof point that EMA had responded with more resources where needed. "After that we moved on to other areas and are taking it piece by piece," Iannaccone says. "You can look at where the big money and the low-hanging fruit is and then target it more and more in successive rounds." An added luxury was the ability to monitor the process in a steady state to see if EMA was maintaining its achievement.
Data in Context
With health care workers and administrators making different kinds of decisions in different timeframes, it was essential to present data in formats appropriate to the recipient. For the client, immediacy is less of a factor and reports can be assembled from aggregate data collected over time. As things move down to the tactical and operational levels, data becomes more granular, time-sensitive and connected to individuals. At each facility, administrators are delivered standard monthly reports and statistics that relate the performance of each doctor in terms of patients seen, the severity of their conditions, time to be treated, patients who unexpectedly return to the emergency room in 72 hours and so on. Rothman cut the paper trail by putting several graphs on a single page, which provides summary, at-a-glance information for each department. (Fig. 2.)
Figure 2: Role-Based Data
At St. Barnabas, Freer uses the information in meetings where codes are substituted for doctor's names. "We've used it as a tool to say okay, this is the average of our department, these are people at the ends of the curve, where do we need to move?" Freer says. "It has helped a lot, it analyzes and tells me what we're doing now, what we did last year, what's different, and what we could do better."
Performance assessment is a touchy subject in any organization, but in a partnership like EMA, there is a receptive audience provided that the data is correlated to the complexity of procedures performed. "People are still afraid of big brother, but by the same token doctors have gotten evaluations for years with no objective data to back up the scores," Iannaccone says. "There are always people who are annoyed for personality or political reasons, but this is an opportunity to collect objective data on things that matter to the company."
At the operational level, the missing component was some interactive reporting to help administrators deal with daily dynamics. For this, Rothman turned from his build strategy and chose Business Objects products for both the tactical reports and operational dashboards for administrators and other doctors. It proved to be a great leap forward for EMA, a packaged application that in tandem with Oracle could deliver a solution more event-driven than data-driven, and address IT and business needs simultaneously. "The non-technology side deals with the inter-tangling of the thought process between the operations personnel and the IT personnel," Rothman says. "As for technology, whatever you select has to be easy to implement, manage and monitor because like most companies, we have to keep doing more with the same resources."
Data on the Go
Rothman spent a lot of time researching the user interface in the belief that easy access and usability were the keys to adoption and use. Dashboards built with the new application take elements from the standard reports and present them in speedometer fashion, (Fig. 2) which gives more immediate views into operational requirements like staffing. This might suggest a different mix of doctors, nurses, physician assistants or clinical information managers (who handle onsite administrative duties for doctors). "These days, emergency departments are overcrowded and while you want the community to choose your hospital, just about every hospital regularly diverts patients [to other facilities]," Freer says. "The challenge is to get people through when the back end is clogged up and there's only so much room in the funnel."
The system lets administrators at each hospital set acceptable ranges for performance indicators according to capacity. When a range is exceeded, it sets off an email alert that ties back into reports that can be used at different levels of the organization. "You want a single point of access in the dashboard, but it doesn't end with green, yellow and red," Rothman says. "You need to tie back into reports so finance and HR don't spend their day analyzing. Instead, when a metric goes red, an email describes the problem with reports in terms of numbers, how many people walked out, this month versus last month and so on."
This lets users consume necessary information and also analyze to their heart's content. Though he's a hands-on doctor, Iannaccone has an interest in BI and spends hours going through data to find answers to his own questions. "Jonathan [Rothman] doesn't have as much operational experience as I do as a physician and director, though he has picked up an awful lot of it," Iannaccone says. "I have some facility with the tools but he has a lot more. Together we're able to really create some terrific reports for those folks who maybe aren't willing to do their own slicing and dicing."
It's the kind of operational chasm-crossing Rothman was hired to facilitate. "There is a coming together today between a pure technologist and an operations person," he says. "Essentially it's about facilitating change and the process by which change is facilitated. I have always heard that the best project managers for an IT projects are operations persons because it's a lot harder to learn the operations than it is to learn the IT, especially with the advancements these days."
Jim Ericson is editorial director of DM Review, a SourceMedia publication. You can reach him at Jim.Ericson@sourcemedia.com.
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