Playing The Healthcare Analytics Shell Game

When I think of how most healthcare organizations are analyzing their clinical data today … I get a mental picture of the old depression era shell game – one that takes place in the shadows and back alleys. For many who were down and out, those games were their only means of survival.

The shell game (also known as Thimblerig) is a game of chance. It requires three walnut shells (or thimbles, plastic cups, whatever) and a small round ball, about the size of a pea, or even an actual pea. It is played on almost any flat surface. This conjures images of depression era men huddled together … each hoping to win some money to buy food … or support their vices. Can you imagine playing a shell game just to win some money so you could afford to eat? A bit dramatic I know – but not too far off the mark.

The person perpetrating the game (called the thimblerigger, operator, or shell man) started the game by putting the pea under one of the shells. The shells were quickly shuffled or slid around to confuse and mislead the players as to which of the shells the pea is actually under … and the betting ensued. We now know, that the games were usually rigged. Many people were conned and never had a chance to win at all. The pea was often palmed or hidden, and not under any of the shells … in other words, there were no winners.

Many healthcare analytics systems and projects are exactly like that today – lots of players and no pea. The main component needed to win (or gain the key insight) is missing.  The “pea” … in this case, is unstructured data. And while it’s not a con game, finding the pea is the key to success … and can literally be the difference between life and death. Making medical decisions about a patient’s health is pretty important stuff. I want my care givers using all of the available and relevant information (medical evidence) as part of my care.

In healthcare today, most analytics initiatives and research efforts are done by using structured data only (which only represents 20% of the available data). I am not kidding.

This is like betting on a shell game without playing with the pea – it’s not possible to win and you are just wasting your money. In healthcare, critical clinical information (or the pea) is trapped in the unstructured data, free text, images, recordings and other forms of content. Nurse’s notes, lab results and discharge summaries are just a few examples of unstructured information that should be analyzed but in most cases … are not.

The reason used to be (for not doing this) … it’s too hard, too complicated, too costly, not good enough or some combination of the above. This was a show stopper for many.

Well guess what … those days are over. The technology needed to do this is available today and the reasons for inaction no longer apply.

In fact – this is now a healthcare imperative! Consider that over 80% of information is unstructured. Why would you even want to do analysis on only 1/5th of your available information?

I’ve written about the value of analyzing unstructured data in the past with Healthcare and ECM – What’s Up Doc? (part 1) and Healthcare and ECM – What’s Up Doc? (part 2).

Let’s look at the results from an actual project involving the analysis of both structured and unstructured data to see what is now possible (when you play “with the pea”).

Seton Family Healthcare is analyzing both structured and unstructured clinical (and operational) data today. Not surprisingly, they are ranked as the top health care system in Texas and among the top 100 integrated health care systems in the country. They are currently featured in a Forbes article describing how they are transforming healthcare delivery with the use of IBM Content and Predictive Analytics for Healthcare. This is a new “smarter analytics” solution that leverages unstructured data with the same natural language processing technology found in IBM Watson.

Seton’s efforts are focused on preventing hospital readmissions of Congestive Heart Failure (CHF) patients through analysis and visualization of newly created evidence based information. Why CHF?  (see the video overview)

Heart disease has long been the leading cause of death in the United States. The most recent data from the CDC shows that heart disease accounted for over 27% of overall mortality in the U.S. The overall costs of treating heart disease are also on the rise – estimated to have been $183 billion in 2009. This is expected to increase to $186 billion in 2023. In 2006 alone, Medicare spent $24 billion on heart disease. Yikes!

Combine those staggering numbers with the fact that CHF patients are the leading cause of readmissions in the United States. One in five patients suffer from preventable readmissions, according to the New England Journal of Medicine. Preventable readmissions also represent a whopping $17.4 billion in expenditures from the current $102.6 billion Medicare budget. Wow! How can they afford to pay for everything else?

They can’t … beginning in 2012, those hospitals with high readmission rates will be penalized. Given the above numbers, it shouldn’t be a shock that the new Medicare penalties will start with CHF readmissions. I imagine every hospital is paying attention to this right now.

Back to Seton … the work at Seton really underscores the value of analyzing your unstructured data. Here is a snapshot of some of the findings:

The Data We Thought Would Be Useful … Wasn’t

In some cases, the unstructured data is more valuable and more trustworthy then the structured data:

  • Left Ventricle Ejection Fraction (LVEF) values are found in both places but originate in text based lab results/reports. This is a test measurement of how much blood your left ventricle is pumping. Values of less than 50% can be an indicator of CHF. These values were found in just 2% of the structured data from patient encounters and 74% of the unstructured data from the same encounters.
  • Smoking Status indicators are also found in both places. I’ve written about this exact issue before in Healthcare and ECM – What’s Up Doc? (part 2). Indicators that a patient was smoking were found in 35% of the structured data from encounters and 81% of the unstructured data from the same encounters. But here’s the kicker … the structured data values were only 65% accurate and the unstructured data values were 95% accurate.

You tell me which is more valuable and trustworthy.

In other cases, the key insights could only be found from the unstructured data … as was no structured data at all or enough to be meaningful. This is equally as powerful.

  • Living Arrangement indicators were found in <1% of the structured data from the patient encounters. It was the unstructured data that revealed these insights (in 81% of the patient encounters). These unstructured values were also 100% accurate.
  • Drug and Alcohol Abuse indicators … same thing … 16% and 81% respectively.
  • Assisted Living indicators … same thing … 0% and 13% respectively. Even though only 13% of the encounters had a value, it was significant enough to rank in the top 18 of all predictors for CHF readmissions.

What this means … is that without including the unstructured data in the analysis, the ability to make accurate predictions about readmissions is highly compromised. In other words, it significantly undermines (or even prevents) the identification of the patients who are most at risk of readmission … and the most in need of care. HINT – Don’t play the game without the pea.

New Unexpected Indicators Emerged … CHF is a Highly Predictive Model

We started with 113 candidate predictors from structured and unstructured data sources. This list was expanded when new insights were surfaced like those mentioned above (and others). With the “right” information being analyzed the accuracy is compelling … the predictive accuracy was 49% at the 20th percentile and 97% at the 80th percentile. This means predictions about CHF readmissions should be pretty darn accurate.

18 Top CHF Readmission Predictors and Some Key Insights

The goal was not to find the top 18 predictors of readmissions … but to find the ones where taking a coordinated care approach makes sense and can change an outcome. Even though these predictors are specific to Seton’s patient population, they can serve as a baseline for others to start from.

  • Many of the highest indicators of CHF are not high predictors of 30-day readmissions. One might think LVEF values and Smoking Status are also high indicators of the probability of readmission … they are not. This could  only be determined through the analysis of both structured and unstructured data.
  • Some of the 18 predictors cannot impact the ability to reduce 30-day admissions. At least six fall into this category and examples include … Heart Disease History, Heart Attack History and Paid by Medicaid Indicator.
  • Many of the 18 predictors can impact the ability to reduce 30-day admissions and represent an opportunity to improve care through coordinated patient care. At least six fall into this category and examples include … Self Alcohol / Drug Use Indicator, Assisted Living Indicator, Lack of Emotion Support Indicator and Low Sodium Level Indicator. Social factors weigh heavily in determining those at risk of readmission and represent the best opportunity for coordinated/transitional care or ongoing case management.
  • The number one indicator came out of left field … Jugular Venous Distention Indicator. This was not one of the original 113 candidate indicators and only surfaced through the analysis of both structured and unstructured data (or finding the pea). For the non-cardiologists out there … this is when the jugular vein protrudes due to the associated pressure. It can be caused by a fluids imbalance or being “dried out”. This is a condition that would be observed by a clinician and would now be a key consideration of when to discharge a patient. It could also factor into any follow-up transitional care/case management programs.

But Wait … There’s More

Seton also examined other scenarios including resource utilization and identifying key waste areas (or unnecessary costs). We also studied Patient X – a random patient with 6 readmission encounters over an eight-month period. I’ll save Patient X for my next posting.

Smarter Analytics and Smarter Healthcare

It’s easy to see why Seton is ranked as the top health care system in Texas and among the top 100 integrated health care systems in the country. They are a shining example of an organization on the forefront of the healthcare transformation. The way they have put their content in motion with analytics to improve patient care, reduce unnecessary costs and avoid the Medicare penalties is something all healthcare organizations should strive for.

Perhaps most impressively, they’ve figured out how to play the healthcare analytics shell game and find the pea every time.  In doing so … everyone wins!

As always, leave me your comments and thoughts.

Why My Beloved iPhone Now Makes Me Sick To My Stomach

I didn’t know it at the time but my love affair with Apple began on November 22, 1983 … the day I bought my first business.   I was 22.  That fateful decision changed my life in many ways …  and also unexpectedly started a 30-year infatuation with Apple.  My business partner and I purchased a well established, and well known, family owned photo and computer business in the Baltimore-Washington metro area.  The business had a retail component but the real growth (and opportunity) was coming from the commercial division who was just starting to sell personal computers.  Our strength was selling to educational systems.  We eventually sold the business but that’s another story.

In 1983, the computer business was very different world.  Personal computers were just starting to catch on.  This was long before the Macintosh took the world by storm in the mid-80s.  There were a number of players, operating systems and technical approaches vying for viability but markets were beginning to settle around the following segments: personal computers for hobbyists (Commodore 64 and others), personal computers for business (IBM PC and compatibles), and personal computers for education (Apple II series).  Commodore and others faded as Apple and IBM (based on the Microsoft DOS operating system) were the two surviving approaches.  This was long before Windows and is still true today.  The winners from the early 80s are still the winners today.  Even though IBM smartly exited the PC business in 2005, the battle is still fought today between Apple and Microsoft powered personal computers.

Back to 1983 … there were no cell phones, no Internet, no e-commerce, no Apple stores and computers were manufactured in the USA … not in China.  Both Apple and IBM used resellers (or dealers) as their sales channels to market.  Apple even had a unique “black” version of the Apple II that was only sold to schools.  This is where we came in.  We used to sell Apple IIs by the truckload (literally).  We also customized and serviced them from the ground up.

Through all this, I developed an insider’s perspective and a fondness for Apple.  My respect and admiration for Apple has grown over the years.  I’ve stayed connected and involved with Apple in one way or another at key stages of my career.  I applauded the major successes (Macintosh, iPhone, iPad) and chuckled at the failures (Newton, Lisa, MobileMe).  I’ve never had a reason to think poorly of the company.  Until now.

It’s no secret I work for IBM today (see the personal opinion disclaimer).  IBM and Apple haven’t competed with each another for years.  One is corporate … the other is consumer.  I point this out because I have no agenda driving me to write this other then my conscious.

Today, Apple is the most successful consumer technology company by just about any measure.  Skyrocketing stock price, top 10 brand recognition and tons of cash  (~$97 billion).   Apple also stunned everyone with their recent earnings announcement.  During the last quarter of 2011, they made ~$13 billion in profit.   That’s more than twice as much for the same period in 2010, and more than any company has ever earned during a single financial quarter … except one.   Exxon Mobil made over $14 billion in a single quarter (thanks to high oil prices) in 2008.

Are you kidding me?!?!  Congratulations!  They deserve all the spoils and accolades.  Their products work better and are craved by the masses.  Their customer loyalty and devotion is like nothing we’ve ever seen in business before … myself included.  I have an iPhone, iPad and MacBook Air and love them all.  Within the last six months, I stopped using Windows and Blackberry completely.  I outwardly promote how great my experience with the company has been.  Even the AppleCare tech support is great … at a time when most companies call centers are a joke or non-existent.

But wait a minute, something doesn’t add up for me.

It’s the China worker thing.  Over recent years … as Apple’s bank account has increased … so have the charges about labor conditions in iPhone factories in China.  The New York Times, The Huffington Post and others are zeroing in on this at the moment.  My Mom used to say, “Where there is smoke, there is fire”.   We all know the media can be unreliable on these topics but they can be a pretty good watchdog too … just ask Rupert Murdoch and his staff.

In my mind, there are too many outrageous claims to ignore this any longer!

“Working excessive overtime without days off ” …. “Living together in crowded dorms” … “exposure to dangerous chemicals” … “Two explosions ‘due to aluminum dust’ killed four workers” … “Almost 140 injured after using toxin in factory,” … “Nets on buildings to prevent or deter stress related suicide attempts” … “falsification of records” … “worker suicides” … “beaten and interrogated by superiors over lost prototype”.

I want to know what is really going on.  Are workers really beaten or killing themselves so I can have an iPhone … or so Apple can have even more cash?  Neither is acceptable and both make me sick to my stomach.  This can’t be true, can it?  The more you read the harder you gulp.  It’s making me reach for the Pepto-Bismol.

Apple is certainly not a bad company.  They did donate $50 million to charity in 2011.  But considering how much is sitting in the corporate coffers at Apple it seems light to me.  I mean … they ARE loaded.  Apple donations represent a paltry .1% of their holdings and are a far cry from what others are doing.  Kroeger donates  almost 11% of profits to charity.  Even the allegedly “greedy” financial services firms are more charitable then Apple.  These firms seemed to get blamed for everything but you have to give them credit on this issue (no pun intended).  Morgan Stanley, Goldman Sachs and Bank of America are all among the top corporate givers.

But money is not my issue.  Taking responsibility for your actions is.

I am not an expert on this topic but Apple seems to have a reasonable policy on supplier responsibility.   However, I know from experience that having a good policy is not the same thing as enforcing a policy.  Some of the reports out there are claiming that Apple is not doing enough. In other words, looking the other way and pointing it back to the labor contractors.  Ahhhh … the beauty of outsourcing (if true).

It seems to me; that they hold all the cards and could fix this in about a nanosecond if they really wanted to.  This nonsense has been going on for at least six years and needs to stop.  Are the lower offshore labor costs worth all of this … loss of human life, inhumane conditions and reputation damage?

Apple is truly (and maybe uniquely) in a position to change how the world’s goods are made.  It has the money and the muscle to effect major change.  At the moment, it appears they lack the will, or conscious, to do anything serious about it.  I wonder if too much greed is driving behavior in Cupertino?  The numbers don’t lie.

Tim Cook should seize this opportunity and make this his issue.  Following Steve Jobs as CEO must be an incredibly hard thing to do.  I hope the new guy takes a stand and fixes this, before it is their undoing.  Nike and Wal-Mart both survived offshore labor scandals and so can Apple – but the time for decisive action is now.  Maybe it’s time these jobs come back home to the good ole USA.

I hope Apple grows a conscious soon. With new leadership in place, this should be easier to do.  Good luck Apple, I still love you but I won’t wait forever for you to fix this and I hate the taste of Pepto-Bismol.  Seriously, I wouldn’t normally blog about something like this but I felt the need to do something.

The Chinese government needs to man-up as well.  The economic growth in China is literally being fueled by blood, sweat and tears (not a joke) of their citizens.  I can only hope the conditions are not as extreme as being portrayed.

What about you … does it turn your stomach also?  Are you outraged?  You should be.

Blog update on February 13, 2011Apple issues statement about labor situation in China.  What do you think?  A strong enough response?