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BPM Could Cure Clinical Information Headaches

Healthcare organizations today are caught among three often opposing forces - the need for greater efficiency in the delivery of care to cut costs, the need for better patient safety, and the need to comply with emerging protocols from payer organizations. IT plays a crucial role in the solution to this dilemma, but the complexity of healthcare service delivery demands "real-time" methods to direct clinical behavior, improve the delivery of care, enhance quality and reduce errors. While prior investments have focused on data availability, the solution is not another super-application with its consequent costs and risks.

Rather, as other industries are finding, a better answer lies in a new approach to integrating and coordinating existing technology at the business process level and putting the power of that coordination in the hands of those closest to the business issue.

A tale of two data sets

Healthcare IT innovation usually lags that of other industries by three to four years because it has some unique circumstances that make the integration and coordination of clinical information both more pressing and more challenging. For example, communication timeliness and accuracy can often be a literal matter of life and death. Healthcare transactions are also very complex, and they occur on many different proprietary systems simultaneously. These issues, coupled with the language barrier between clinicians and healthcare business executives and the frequently changing regulations for reporting data have heightened the IT challenge of making the most efficient use of data.

Recent state and federal regulatory changes, along with Medicare's shift toward "pay for performance," has increased pressure to quantify quality and efficiency in healthcare delivery. In data management then, the focus has shifted to the problem of extricating data from existing systems, rather than looking for a new set of systems to solve the quality quantification problem. However, these efforts have been complicated by the fact that the data is locked in a multitude of independent, often incompatible systems hospitals have invested in over the years.

While there is now enough data being collected within individual systems getting at it and making it actionable in real-time has remained an obstacle in the quest to improve healthcare quality and efficiency and decrease medical errors.

Creating event-driven architectures

Business process management (BPM) technology is at the forefront of an emerging trend toward event-driven architectures that holds great promise for addressing the fundamental challenges of today's clinical information management environment.

Using technologies such as Web services and extensible markup language (XML), BPM technology offers a lightweight, highly flexible way to turn existing applications and systems into a real-time, event-driven infrastructure. The technology forces no changes to existing applications, makes integration of additional systems a trivial matter and serves three key functions:

1. monitoring for events (transactions) and building a history of all the transactions occurring in that application in a standard business intelligence tool for detailed analysis;
2. sending appropriate "alerts" to caregivers, administrators, or other departmental systems when a series of events occurs and those alerts match the preset "rules" criteria; and
3. enabling modification of "rules" by non-technical staff based on key feedback.

Because of the huge increase in the number of tests and remedies that can be ordered by physicians, it is inconceivable that any one physician in an emergency department (ED) could stay current on the details of their proper use. In addition, the liability crisis has encouraged over ordering of tests as a defensive measure.

Without effective management, wasteful practices can limit access to those needing resources and cause a financial strain on both providers and patients. Below is an example of how an event-driven architecture can turn insight about an existing problem gleaned from static data analysis into a new system-spanning process designed to address the problem in real time.

A hospital made available a new test, D-Dimer, to ED physicians in 2002 to help rule out diagnosis of a blood clot to the lung and the need for follow-up testing such as a CAT Scan. Because this was a new test and no data was available to provide guidance, there had been no physician education done instructing how the test should be used and what would be monitored to assure the new test was used appropriately.

In the graph below, a dramatic upward trend in D-Dimer tests can be seen at its introduction. Follow-up CAT Scan tests were also still being ordered frequently. Without the ability to access and analyze its data in a timely fashion, the hospital had only an anecdotal sense that the test wasn't being used effectively.

By February of 2003, with effective data analysis in place, the hospital was able to learn that if the D-Dimer result was negative in a low risk patient there was almost no chance of the patient having a clot to the lung and therefore no reason to get a follow-up CAT Scan. The hospital was then able to educate ED physicians that only when the probability for a clot to the lung is moderate to high then the follow-up CAT Scan should be performed without ordering the D-Dimer.

By April of 2003, the hospital was educating its doctors in the proper use of the test and, as can be seen in the graph, follow-up CAT Scans drop off dramatically and D-Dimer ordering becomes more prudent.

Delays in understanding and acting on data have consequences both in terms of operational efficiency and costs. In the case of this hospital and its experience with the D-Dimer test, an analysis of cost tables (shown in the graph below) revealed actual savings seen after the physician education and monitoring of their practice was undertaken.

If the training that occurred in April of 2003 had occurred at the time of the test introduction, the total savings would have been $150,000. The next logical step is to turn understanding into a real-time process that can affect behavior.

Using the example from above, the hospital would first identify the systems supporting the process it wished to affect. In this case, it would be systems and applications in the laboratories for ordering tests and entering test outcomes. BPM integration technology would connect the disparate systems using lightweight adapters to listen for events on the systems and a rules engine to allow coordinated action among them.

In attempting to more effectively influence physician behavior, a clinical leader using a BPM-integrated system could easily configure the following process across multiple systems:

1. The technology is instructed to monitor for an event on the lab system - "D-Dimer test ordered."
2. The "rules engine" is instructed if event "D-Dimer test ordered" occurs, then monitor radiology ordering system for event "follow-up X-Ray study."
3. When the event "follow-up X-Ray study" occurs in radiology, the rule would trigger a check of the lab system for D-Dimer completion and result.

If the lab system check returned a status of "not back" or "negative" the rule would immediately trigger an alert to the physician, prompting them to consider waiting for the result of the D-Dimer test and, if negative, to consider or reconsider the usefulness of follow-up X-Ray. In a clinical setting such as this, it's important to preserve professional prerogative, therefore the system could be set to allow the physician to override the alert and order the follow-up X-Ray. However, the ability of this technology to put process design control in the hands of clinical leaders who understand the needs and behaviors of the people using them greatly increases the likelihood that desired results would be realized.

Conclusion

Physicians and clinical leaders have more important things to worry about than how their IT systems manage data. They just need the systems to provide the coordinated data access and automated event-driven information that will help them save lives while complying with the federal regulations. BPM integration technologies can provide the framework to unite previously siloed systems to work together to help physicians do their jobs better.

This article appeared in the April 2005 issue of Database Trends and Applications.