The Great Aggregation

June 24, 2011
Marcus Bost The dream of one enterprise system for different applications has not exactly turned out the way many in the industry had hoped. Though
Marcus Bost
The dream of one enterprise system for different applications has not exactly turned out the way many in the industry had hoped. Though some core vendors offer limited accessibility to their own clinical offerings in one screen, hospitals have too many standalone clinical applications and not enough integration functionality.

While physician portals can tie many of these applications together, a more complete solution that some are embracing is aggregation, which brings information together and places it at a user's fingertips without multiple sign-ons or screens. And because aggregation solutions are vendor agnostic, they can combine and deliver patient information from multiple sources in a standard format, relatively easy to compare and analyze.

“Having all the information in one spot just makes sense,” says Marcus Bost, CIO of Adena Health System, a two-hospital system in Chillicothe, Ohio, who is using a portal aggregation solution from Medseek (Birmingham, Ala.). “You couldn't imagine having to look at the stock exchange and going to 16 different screens,” he says. “For us to be catching up to other industries is the long-delayed transformation in healthcare.”

And as hospitals go to pay-for-performance and get fed new information and protocols, most feel that information is going to be the lifeblood of healthcare, just as it is for other industries.

Larry Stofko, senior vice president and CIO of 14-hospital St. Joseph Health System in Orange, Calif., is an early adopter of Amalga, Microsoft's (Redmond, Wash.) aggregation solution. He says that information from these IT solutions fills the needs of a changing healthcare system. “The paradigm used to be data into information, and then into knowledge,” he says. “What we're doing now is taking it a step further - data into information, to knowledge, and now, to action.”

Recently, Orem, Utah-based KLAS examined available aggregation solutions that provide a single view of clinical data from disconnected systems and interviewed hospitals to see how aggregation vendors are delivering on the promised benefits. According to KLAS, from a functional standpoint, dbMotion (Pittsburgh) and Microsoft are in one peer group, while Carefx (Scottsdale, Ariz.), Medicity (Salt Lake City), Medseek (Birmingham, Ala.) and PatientKeeper (Newton, Mass.) comprise a second group.

“This is a new area that's gaining a lot of traction really quickly,” says Chris O'Neal, director of corporate reporting at KLAS, and a principal author of the report. “Though only 85 hospitals in the U.S. are currently using aggregation solutions, there is a lot of interest.”

The Microsoft and dbMotion peer group markets platforms that, in essence, can replicate the databases from 100 or more systems by aggregating on the back end - and Microsoft also offers the capability to integrate with its HealthVault personal health record (PHR). According to the KLAS report, while vendors in the other peer group have shown the ability to connect with a handful of primary and secondary systems, they still have challenges in branching out much further. Though they do a satisfactory job of aggregating information, they act more like physician portals. So with such a range of function, is there any one clear winner?

While each solution has its pros and cons, in the end it comes down to the healthcare system.

“It really depends on the customer, and what are their goals,” says O'Neal. Large hospital systems with huge quality initiatives want to do business intelligence reporting in addition to aggregating data across the IDN for physicians, and for these, O'Neal says an Amalga or dbMotion makes sense. “The value of solutions like Amalga only increase over time,” he says. “But if you look at a small hospital that's been on its core clinical for years, it may be important to them to save their money and go with one of the other aggregation solutions.”
Jeremy Bikman

What kind of money? The purchase can run to $1 million for Amalga, while one of the portal-like solutions can run about $200,000. And, adds O'Neal, no one knows yet what add-ons might cost for a solution like Amalga.

Though cost is one factor, it's not the only one, says Jeremy Bikman, vice president, research and strategy at KLAS. “When you factor in the level of IT strength in an organization, budget, where they are with IT adoption, executive support and advanced clinicians, it really changes the dynamics,” he says. “So where Amalga or dbMotion might be perfect for one client, it might not work for another.”

Bikman says he believes hospitals will have to get an aggregation solution, but what they choose depends on the IT lifecycle at the hospital. “The Partners and the Mayos already have their strategic plan and are moving on to the next thing,” he says.

While his organization is not quite as wired as Partners HealthCare or the Mayo Clinic, Adena's Bost says he is finding that his Medseek solution works perfectly for his needs, and has been driven mainly by physicians. “We're always looking for ways to make our doctors more productive and this was one,” he says. At Adena, 2008 was dubbed, ‘The Year of the Physician,’ and the Medseek aggregation solution was one of the tools Bost introduced.

“We brought everything we have, including the kitchen sink, to the desktop for the physicians: all ancillaries, labs, ED, blood - it's in there,” says Bost, whose hospital had a 15-year history with Meditech (Westwood, Mass.). Bost says his physicians found the Meditech solution cumbersome to use. “You can't leap from deep within one tunnel to deep within another.”

Bost says when he began looking for an aggregation solution, it was before Microsoft's wasn't yet available. “We chose Medseek due to its level of integration and the pieces we could bring in, specifically within the Meditech space,” he says “That's what sealed it for us.”

But for those large hospital systems that are already on to the next big step, KLAS' other peer group of Microsoft and dbMotion can be a game changer.

“As we move into the future with the delivery of healthcare, we may not even know the questions we want to ask five years down the road,” says Stofko, who went live with his Amalga solution in 2008. “So we can look at potential correlations, look at things together that we might not have thought would be associated.”

That approach is part of St. Joseph's strategy of expanding from a hospital-based delivery system to a broader based community delivery of health and wellness. “We wanted to spend more time acting on the information than looking for it,” he says.

According to Stofko, Amalga has unique capabilities from a CIO's perspective as compared to a data warehouse. He says the traditional data warehouse approach is to bring in a consulting company, then spend a lot of time and money doing an inventory of all the data sources. “And then six months and half a million dollars later, you're ready to start doing a vendor selection,” he says. “We basically bought Amalga, turned the existing interfaces on, and right now we probably have over 300,000 transactions on a daily basis.”

As part of its implementation strategy, St. Joseph's asked 100 leaders in the organization to identify scenarios that could help them directly, either in business operations or delivery of care. Stofko then held a workshop where 40 people began to craft scenarios where data was very important to them. “We called these base views,” says Stofko, and those were demo-ed to the whole organization. “We're in the process of building the indicators, the measures, and we've finalized our security matrix for access - do you need to get to the patient level or not?” Right now, since Amalga is not fully rolled out, St. Joseph's has 60 people across the organization using it, but plans to be up to a few thousand in the next six months.

Another goal is an expansion of HealthVault capabilities for St. Joseph's, which has a limited integration with the current version of Amalga. Stofko says the first project will be an electronic baby book that will be HealthVault compliant so parents of a newborn will be able to opt-in for an e-version of all the baby's health information. “It's the first generation starting out with an electronic health record,” says Stofko.

Yet with all the benefits, there are still challenges to be met. Security, for example, is a big hurdle.

“The biggest part was figuring out all the rules around the physicians,” says Bost, adding that he started getting requests from physicians wanting to get in to the portal that weren't doing business with Adena. “There were a lot of people that came out of the woodwork and we hadn't expected that,” he says. “We had to get the policies and procedures in place; we had to educate IT and our help desk about how to handle this.” And as Adena continues to roll out its EMR, Bost says, he will have to keep tweaking the solution.

And Amalga has its own set of challenges - one that was a surprise at St. Joseph's, where Stofko found he needed to manage users expectations. “You will get people within the organization that think because we've made this investment, we don't need to make any more investments.” How does he deal with an organization that feels Amalga will basically wash their car? “By pulling people together and demonstrating as appropriate and educating where the product is going, showing them a roadmap,” says Stofko. “That active engagement is the only way.”

And today's economic climate may play a big factor in adoption as well.

“The interest is exploding, but given its size and scope, you don't have a lot of contracts flying off the shelves,” says Bikman. “Everyone's coming at it from a different angle, and the stimulus package is going to cause some of these guys to adjust.” He explains that hospitals that may have been potential candidates for these solutions now may, in the next two or three years, have to pick a core clinical system. And for those already down the EMR path, the stimulus may be an incentive to purchase.

Does KLAS have any advice for CIOs considering an aggregation solution? Two words, says O'Neal: Be careful. “Even though there's been some real success we've seen from Amalga and dbMotion, these systems are still being formed,” he says. “You may not be able to compare with where they're going to be in two years.” He believes portals are easier for a CIO to understand. “You know what they are, they aggregate, they serve a real need, and they've done a good job of fitting into their niche market.”

Indeed, Bost says that when he goes live on Meditech's 6.0, which will include a portal, he plans to continue with Medseek. “We see value in it.”

O'Neal says he expects the future to be dynamic, especially due to the stimulus package. “If they have a big Medicare patient mix, if they have a go-forward core clinical strategy, or they're going to get a core clinical strategy, they're looking for what's that next thing.” From what he's seen, he says, aggregation may be one of those top three or four next big things. “The sexiness factor for these is very high, but we'll see what happens in a few years. Not even their customers know what these things are capable of.”


From Evidence to Experience

Larry Stofko
Larry Stofko, CIO at St. Joseph's, has seen some interesting benefits from Amalga already, writing information between Meditech and his Raiser's Edge fundraising software,. Stofko says that instead of having to write eight point-to-point interfaces, he was able to just dump the fundraising information into Amalga. And, he says, he can pull out stats immediately that would have taken three people three days to do. Stofko tells the story of how one physician demonstrated the power of Amalga: “We were doing a demo and a physician said, ‘I'm going to look at all the patients that expired in the health system over the last year and sort them by men and women.’ It came out to 50/50. But then he filtered it at age 50 and below, and it flipped to 2/3 men. It's that taking it to the next level of things you can do - the zip code, the diagnosis, things like that.” Stofko sees the ability in the not-so-distant future to begin using experience-based data instead of evidence-based - to see how they treated the last 100 people that came into the ED, for example, and what was the cost and what was the outcome. And with evidence-based protocols, he says information can take five to seven years before being published.
Healthcare Informatics 2009 May;26(5):14-18

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