TABLE OF CONTENTS (RIGHT CLICK TO UPDATE)

EXECUTIVE SUMMARY...............................................................................................3
Project Description......................................................................................................................3
Project Environment....................................................................................................................3
Project Recommendation............................................................................................................3

CURRENT US REIMBURSEMENT FRAMEWORKS.......................................................4

Current US Reimbursement Frameworks....................................................................................4
Fee for Service Model..............................................................................................................4
Capitation Model......................................................................................................................4
HMO/Managed Care I..............................................................................................................5
P4P............................................................................................................................................5
Geisenger..................................................................................................................................5

PROPOSED PROMETHEUS REIMBURSEMENT FRAMEWORK....................................7

Overview of Prometheus.............................................................................................................7
Strategic Goals and Objectives....................................................................................................7
Improve Patient Health............................................................................................................7
Radically Improve Efficiency of Overall System.......................................................................7
Align Incentives & Utilize Data.................................................................................................7

PROPOSED TECHNICAL SOLUTION............................................................................8

Data Flow Processes....................................................................................................................8
Integration of Existing Medical Terminologies............................................................................8
Hardware Requirements.............................................................................................................9
Software Requirements...............................................................................................................9
Procurement of Technology......................................................................................................10

PROPOSED ANALYTICAL ENVIRONMENT................................................................11

Reporting and Decision Support System...................................................................................11
What is decision support and what constitutes a decision support system.............................11
How can DSS be applied to healthcare, what is its value?........................................................11

PROPOSED GOVERNANCE STRUCTURE...................................................................13

Importance of Change Management........................................................................................13
Key Governance Components...................................................................................................13
Information Technology.........................................................................................................13
Medical Analytics Team.........................................................................................................13
Business Intelligence Competency Center.............................................................................14
Proposed Staffing Roles and Responsibilities............................................................................14
Information Technology.........................................................................................................14
 Medical Analytics Team.........................................................................................................14
Business Intelligence Competency Center.............................................................................14

APPENDIX 1: LEGAL / ETHICAL CONSIDERATIONS...................................................18

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EXECUTIVE SUMMARY

PROJECT DESCRIPTION
For our project we will be analyzing a novel reimbursement method to replace/supplement the
current fee for service and capitation reimbursement methods in the US. The reimbursement
model we will analyze is a “real” reimbursement method that has been developed over the last
five years by The Commonwealth Fund and the Robert Wood Johnson Foundation. It’s called
PROMETHEUS. The format of our project will be a proposal for a pilot implementation of
PROMETHEUS at a fictional HCO but based on our individual experiences.

PROJECT ENVIRONMENT
Paramount Health Care Organization (PHC) is one of the largest groups of hospitals and
physician practices on the East Coast. It consists of 19 hospitals and 23 physician practices. The
organization has been sustaining revenue losses, consistently for the past two years. The senior
executive team, based on the research provided by the finance department, has determined that
there is a strong need for payment reform and better reimbursement method. The CEO has
proposed that the HCO, in partnership with the regions primary third party payer, pilot a new
reimbursement method called PROMETHEUS. The CEO has requested a proposal for the pilot
program that includes an analysis of potential impacts across the HCO and its partners. The CEO
it is proposed that the pilot project take place at their largest metropolitan hospital, Atlantic East
hospital in Sellersville.

The project has been forwarded to the business intelligence and analytics informatics team. The
deliverables are a business case for implementing the new payment method and prototypes of the
following: Data Flow Processes, IT infrastructure, Reporting and Decision Support System, and
the Governance model necessary to manage the new structure. Use of the Extract, Transform and
Load (ETL) process for cleansing, validating and loading data in data marts that will house
meaningful data required for use of measuring efficacy of the PROMETHEUS system.

PROJECT RECOMMENDATION
xyz

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CURRENT US REIMBURSEMENT FRAMEWORKS
In this section we will build a business case that explains why it is necessary to switch to the
Prometheus model. We start out with some background on the major types of reimbursement
models and then discuss how a Prometheus model can help achieve our Strategic Goals and
Objectives.

CURRENT US REIMBURSEMENT FRAMEWORKS

Fee for Service Model

Pros

 Easier for physicians/providers to manage

 Simplest of all models - you do X you get paid Y
 Patients that can afford to pay out of pocket can go wherever they want
 Providers can charge whatever they want
 No capitation for service
 Minimizes risk for payers
 Good for outpatient services and routine preventative care
Cons

 Not everyone can afford it

 Encourages waste/over treatment
 No connection to quality
 Risk of poor quality/excessive treatment is shifted to patients/providers
 Patients have to pay out of pocket for expenses not covered by plans
 Not sustainable
 Most providers and payers have abandoned this model.

Capitation Model
Pros

 Payers pay a flat rate for management of diagnoses (DRGs for Medicare). For
example, $10,000 will be paid for acute myocardial infarction.
 Risk is minimized for payers
Cons

 Risk of unforeseen heath event is shifted toward provider and patient

 Providers have to minimize length of stay and choose the most least expensive
measure of treatment might not be most efficient
 Providers are forced to develop a volume-based mentality vs. patient centered
quality mentality
 Not sustainable

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  Quality outcomes compromised

HMO/Managed Care I
Pros

 One-stop shop, convenient for patients, payers and providers

 Lower cost healthcare
Cons

 Risk is shifted toward provider and patient

 Patients do not have the option of selecting physicians or hospitals
 Providers are forced to develop a volume-based mentality vs. patient centered
quality mentality
 Sustainable but with toxicity

P4P
Pros

 Risk is minimized for payers

 Providers are mandated to provide higher-quality increase quality benchmarks of
care, as evidenced by outcomes reported
 Patients benefit by higher-quality care
Cons

 Risk is shifted toward provider

 Once quality benchmarks are achieved; there is no guarantee of increased revenue
 Lacks incentives for care coordination
 Shift of care focuses toward reaching quality benchmarks rather than true patient
care
 Not sustainable; providers will abandon this model based on no true monetary
incentive in exchange for higher quality
 Providers are not reimbursed for hospital acquired co morbidities/infections

Geisenger
Pros

 Fee-for-service global rate for services rendered. For example $100,000 for open-
heart surgery.
 90-day warranty that no postsurgical complication will occur. If postsurgical
complications do occur, then the cost of re-hospitalization, or any other care, is
absorbed by the hospital

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  A very thorough pre-and post-surgical follow-up is provided to prevent any type of
card complications that can result in additional cost than the global fee rate
 Evidenced based outcomes used for quality reporting
Cons

 Limited to certain types of surgeries only

 Cannot be used in a medical home model of healthcare
 Risk is shifted toward provider and patient

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PROPOSED PROMETHEUS REIMBURSEMENT FRAMEWORK

OVERVIEW OF PROMETHEUS
Pros

 The best of all the models is extracted in using this model. Aligns health care deliver
risks with health care providers and unforeseen health care occurrence risk with
Insurance companies. For example, fee-for-service is used for preventative
medicine and routine checkups. Also incorporates standard fees for predictable
treatments. Capitation is used for routine procedures such as labor and delivery and
other low risk hospitalizations. Rewards quality with bonus pool P4P is used for
potentially avoidable costs, which are in the form of an incentive held back as a
select dollar amount that is issued to their physician/provider if the patient does not
develop any avoidable computations. Encourages holistic system approach to health
care by focusing on entire episodes of care and not just one part of a treatment.
Global fee is used for surgeries and other procedures.
Cons

 New system, hypothetical. No pilot tests have been conducted to determine the
efficacy of this model.

STRATEGIC GOALS AND OBJECTIVES

Improve Patient Health

o Improve Quality Outcomes
o Improve patient satisfaction
o Deliver Patient Centered Care based on medical home model of healthcare delivery

Radically Improve Efficiency of Overall System

o Increase Coordination
o Decrease Cost
o Provide appropriate services
o Improve reimbursement methods
o Improve revenue stream
o Find sustainable payment model

Align Incentives & Utilize Data

o Distribute Rewards based on how well you manage what you influence
o Set clear Evidence Based targets
o Provide actionable data and feedback
o Improve physician recruitment and retention

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PROPOSED TECHNICAL SOLUTION

DATA FLOW PROCESSES

I think this is were we can add Andrew’s slide and some discussion about how the Prometheus
model will require pulling data from many different systems, Inpatient EMRs, Outpatient
Physician Records, Outpatient services, Pharmacy systems, Radiology, Lab, ADT, Financial, etc.
Below is a list of the major systems feeding Northwestern Memorial Hospital’s EDW. I think we
need to show/discuss how the Prometheus model requires the use and integration of data from
across multiple systems. Besides aligning incentives for those that can influence outcomes and
processes the key aspect of Prometheus is turning data into information to help make decisions
and improve our knowledge as to what type of care provides the best outcomes. So this is
where we discuss that process, the collecting, organizing, and storing data from source systems
to the central repository using the ETL process.

•  Cerner-Inpatient •  Tumor Registry

•  Epic-Outpatient •  Audit

•  Primes- ADT System •  Prosolv

•  IDX •  Intellidose

•  Master Reference Data •  Sentillion

•  NOTIS •  E-IRB

•  Xcelera Ancillary System •  Social Security Death Master Index

•  MedicalManager •  OTTR-Transplant System

•  PsPore •  Vocabs

INTEGRATION OF EXISTING MEDICAL TERMINOLOGIES

I am not sure if this part stands alone. It might make sense to have this as part of the data flow
section. So in the process flow we start with something like:

A key aspect to manage when working with healthcare information systems is the
challenges around integrating the different terminologies.

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Then follow with a few sentences or a paragraph on the main terminologies.

 Definition of different medical terminologies that may be found in our data mart
 ICD-9, DRG, CPT, HCPCS, RxNorm, SNOMED-CT?
 Categorizing Issues-How to categorize them
 Mapping issues include Staff required to map codes
 Legal implications if any
 Compliance issues
 Billing implications if any
 Handling Updates
 Uniformity of terminologies during data exchange among autonomous systems
 Proper coding for proper reimbursement

HARDWARE REQUIREMENTS
Here I think we need to discuss the hardware and software necessary for EDW to capture the
data and allow for the reporting. David can you help in this area? We can add the Cisco
automated data capture info here as well. Please read the article that’s posted on file exchange.
Here is a list of information that I have from Northwestern’s EDW infrastructure but I am not
sure if we need anything else.

The EDW is run on two Dell PowerEdge 6850 servers with 64 GB of RAM and dual-core 64-bit
Intel Xeon processors running Windows Server 2003. One is dedicated to the database and the
other to Reporting Services. The database storage solution is an EMC Clariion CX3-80, with the
EDW using 110 drives in 2 metaLUNs.
The database itself is SQL Server 2008, with SQL Server Reporting Services as the platform for
data delivery and SQL Server Integration Services as the platform for developing ETL.

SOFTWARE REQUIREMENTS
What is the platform itself? We have identified the hardware and reporting suite, but need to
identify this there is a healthcare centric data warehouse we can use as a start for the platform.
In my mind we would start with an off the shelf warehouse then develop PROMETHEUS specific
groupers on top of that.

PROCUREMENT OF TECHNOLOGY
 Build vs. Buy vs. Outsource
 Functionality
 Customization

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 Vendors that offer this option
 Do they really have the experience?
 Is there system open enough for all of our systems?
 Stability of the Company
 How flexible are we to change our process to fit the vendor’s business requirements
for PROMETHEUS payment system.
 How reliable or quick is their service
 Internal build
 Do we have the technical expertise? Staffing-do they have work after we finish?
 Can we manage the software and implementation processes?
 We develop the deep knowledge that comes with developing such a system
 Security
 Maintenance
 Temporary
 Permanent
 Costs
 Hardware
 Software
 Time
 CER process
 3 vendor quotes
 MD Buy line

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PROPOSED ANALYTICAL ENVIRONMENT

REPORTING AND DECISION SUPPORT SYSTEM

All improvement programs require accurate and actionable data upon which analysis can be
performed, decisions can be made, and knowledge can be acquired. Thus it is the decision
support capabilities of Paramount Health Care’s (PHC) IT system which will enable PHC to
achieve its strategic goals and objectives.

WHAT IS DECISION SUPPORT AND WHAT CONSTITUTES A DECISION SUPPORT SYSTEM

• Define decision support
• History of decision support
• Example of a decision support system
• Difference between Business Analytics (queries) and Business Intelligence (data
mining). Basically my view and I need to confirm is that business analytics is
essentially driven by users knowing what they want and asking for the information
in a summary form, table, graph, etc. Business Intelligence is more performing
various statistical experiments on the data looking for patterns and links not thus
far envisioned

HOW CAN DSS BE APPLIED TO HEALTHCARE, WHAT IS ITS VALUE?

• Healthcare data exists in separate systems as silos
• No full picture of patient’s health, treatments/tests, patient compliance, insurance
coverage, costs
• Helps with cost management by providing alternative options of treatment .
• Helps with decision making in conditions of uncertainty
• Measures probability of outcomes of treatments, surgeries, procedures etc.
Examples of questions to be asked, data mining operations used and management of report
development

• Standard reports can be pre built by central research analysts/report write for
those reports that are needed every day/week/month on same data i.e. all PN
patients who have not receive pneumovax, all ICU patients whose daily check list
show they still have a central line or Vent but are missing daily confirmation of
need, all patients with bills over X amount or LOS is within 1 day of target LOS for
that patient type
• Custom Reports can be built by central research analysts/report write or
distributed data analysts employed by a specific unit or department can build
report based on report request. This can also involve meetings and consulting with
individual requesting report and opening up a project

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 • Enhanced queries/data mining can be developed by EDW software engineer and
client for questions that require extensive data manipulation, new tables to
constructed or data mining employed

Questions

 How specific/Technical do we need to be? Define basic table names?

 Do we need to specific which systems would have supplied the data?
 Should we address frequency of the report?
 Where do we discuss who would access report, and show how user would access
and use information - i.e. at bedside on daily rounds on PC or printed report to nurse
manager?
 What specific cases/examples need to be developed to tie our decision support back
to Prometheus?
 Once the technology is operationalized, what will it do for us?
 Opportunities for leveraging the data warehouse
 Case management
 Disease management
 Demand management
 Utilization and referral management
 Clinical performance measurement
 Predictive analytics
 What about reports showing financial information?
 Cost and revenue per patient type (are these hospital based or physician/clinician
based) how type of reports would tie into the Prometheus system
 What about reports for physician practices demonstrating success in following
evidence based guidelines?
 What about using decision support to help in real time to find all patients meeting
diagnosis that requires Core Measure reporting? Then report provides exception
when missing part of required care or documented exception is missing? Example of
pre populating core measure data so nurses do not have to abstract data and
patients can get complete care in hospital as opposed to clinicians finding out after
discharge?
 How about providing reports for Ongoing Professional Practice Evaluations for
medical staff and nursing Magnet?

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PROPOSED GOVERNANCE STRUCTURE

IMPORTANCE OF CHANGE MANAGEMENT

Managing the change at the HCO Change imperatives

 Setting the new culture

 Supporting new staff
 Incentivizing a successful change
 Encouraging innovation
 Training and learning planning
 Senior executive team responsibilities
 Promote a collaborative relationship between IT and business management
 Facilitate stakeholder involvement in implementation of informatics projects
 Promote culture of data-driven decision making
 Ensure alignment of investment strategies
 Ensure business ownership of systems development
 Ensure clear ownership, roles and responsibilities for data security
 Risk Management of the implementation

KEY GOVERNANCE COMPONENTS

Information Technology (Responsible for technically supporting and implementing the
technology platform)

• IT Director Reports to IT group

• Typical IT guys

Medical Analytics Team (Responsible for using the data warehouse to conduct analysis
including Prometheus Payment analysis)

• An IT Director?? Or a Finance Director?? Reports to VP of operations (COO) or CEO

• Research Analyst
• Disease mgmt ROI
• Case mgmt ROI
• Quality/Outcomes Measures
• Patient profiling
• Provider profiling
• Overall non system Benchmarks
• Episode grouping
• High cost / high risk patient identification

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 • Patient compliance measurement
• Prescription patterns

Business Intelligence Competency Center (Responsible for the strategic management of the
data warehouse, targeted investment, expert support)-I think the data stewards have to be part
of the unit which generates the data as opposed to being part of a central EDW structure. The
local groups need to feel that they “own” the data and are responsible for the data quality.

• Director of EDW Reports to????

• Software Engineer/DBA
• Project management experience
• Technical Consultants
• Stewards of the EDW tables and structures
• Advanced        
• System Analysts
• Advanced Analytic support
• Data stewards
• Part of the department or unit that “owns” the underlying data.
• Their system generates data loaded into EDW.
• Responsible for data quality
• Have final say as to who has access to data that comes from their system

Here are the some basic responsibilities for the Research analyst and Software engineer that I
have from NMH, which I think, might be helpful in this section:

PROPOSED STAFFING ROLES AND RESPONSIBILITIES

Information Technology
IT Staff descriptions, roles, responsibilities

Medical Analytics Team

Descriptions, roles and responsibilities

Business Intelligence Competency Center

Descriptions, roles and responsibilities

The Research Analyst/Report Writer is responsible for providing data consumers with reports
from the Northwestern EDW. The data analyst will work with physicians, researchers, and other
data consumers to define requirements, formulate queries, validate results, manage the

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approval process, and generate reports using Microsoft SQL Server Reporting Services. The data
analyst will also interface with data architects and application developers to define
requirements for new data structures and web applications to aid in reporting. Additionally this
position will work with peer Research Analyst/Report Writers to collaborate on defining best
practices and knowledge sharing.

Minimum Qualifications/Competencies

 A bachelor's degree in computer science or related discipline, or equivalent education

and experience
 One to three years professional experience in programming or reporting
 Exceptional interpersonal skills, including the ability to establish and maintain effective
relationships with physicians, management, staff, and other customers
 Demonstrated customer service skills, including the ability to use appropriate judgment,
independent thinking and creativity when resolving customer issues
 Expert-level SQL skills
 Ability to balance multiple priorities
 Excellent verbal and written communication skills
Preferred Qualifications/Competencies

 Experience with Microsoft SQL Server Reporting Services tools is preferred, however
other relevant experience will be considered
 Web development experience
 Experience with medical data

The EDW Senior Software Engineer will create and enhance software solutions for the
Enterprise Data Warehouse (EDW) team in the NU Biomedical Informatics Center (NUBIC). The
focus will be on applications that streamline EDW operations, applications that provide EDW
data in a clinical research setting, as well as developing novel algorithms for the analysis of
data. The position will utilize Microsoft C#, ASP.NET, and APIs for the Microsoft SQL Server
Enterprise Edition suite of applications (Reporting Services, Integration Services, and Analysis
Services). Occasional reports for EDW end-users will also be developed.

The position will serve as a technical lead for software engineers on the team and be
responsible for developing, documenting, and enforcing best practices for coding, testing, and
software release management.

Minimum Qualifications/Competencies

 BS in Computer Science or equivalent education and experience

 Three to five years professional experience in software development role
 Demonstrated experience building and maintaining C# and ASP .NET applications
 Experience implementing software testing framework
 Expert understanding of SQL and database design

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  Demonstrated outstanding documentation practices Excellent oral and written
communication skills
Preferred Qualifications/Competencies

 A master's degree in Computer Science, Engineering, or relevant discipline

 Experience in health care computing environment
 Experience with Microsoft SQL Server Integration Services, Reporting Services, and
Analysis Services and related Microsoft APIs Experience in Java
 User support and training experience
 Experience with managing software releases with Subversion
 Experience with working in a HIPAA regulated environment

Distributed Data Analysts (DDA) work for a particular department at the hospital or medical
school and use the data structures designed by the Core Team. The DDA has the subject matter
expertise and reports to the local unit but have the basic-intermediate SQL knowledge to
develop reports for the local unit.

Competencies

Understand patterns of care or services

Indentify causal paths or root causes for problems in service delivery

Profile best practice models

Establish benchmarks for continuous performance enhancement

Differentiate mechanisms for achieving high performance

Knowledge Areas

Business knowledge/skills in health care administration

Health medical informatics training and education

Leveraging of health IT for business and value strategy

Healthcare information resources management

Experience

Medical settings

Business settings

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Performance measurement and management responsibilities

Statistical analysis of complex data sets

Not sure how much to say about this next section. Obviously we could do everything else right
but if the change is not managed appropriately we fail so it is critical. I have a lot of stuff on
Change management but do not want to go off the deep end. Is this a separate section at the
end of the paper?

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APPENDIX 1: LEGAL / ETHICAL CONSIDERATIONS
Summarize how data comes from finance, research, inpatient, outpatient, and lab system

• Might have different level of sensitivity to sharing data

• Any ethical issue using data for research
• Implications for patient consent
• Any issue with accessing reports or running queries from web and sending reports
to Gmail accounts
• Discuss auditing and security at the table, column, row, cell level and how are user
names/passwords managed.

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