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Archive for June, 2011

White Paper: Achieving Financial Effectiveness Through Physician Loyalty

by on June 30th, 2011

The one-to-one communication solutions provided by CRM have been the answer to an increasing number of issues faced by the healthcare industry.  CRM can be used to improve care delivery, lower costs, and increase loyalty among the key stakeholders most necessary to organizational success.  This is particularly true in light of the growing physician shortage, which has caused increased competition among healthcare providers for the best talent.

With this in mind, the Healthcare team has written a white paper entitled Achieving Financial Effectiveness Through Physician Loyalty.  

Physician turnover is on the rise. With news that medical schools are now decreasing enrollment, it is likely to become increasingly difficult to attract and retain the best physicians. Since patient satisfaction, and financial effectiveness, is most closely related to the affiliated physician population within a healthcare organization, healthcare providers need smart solutions to increase physician loyalty in order to maintain patient rosters and grow financial returns. Although a popular choice, operational tactics, such as increasing administrative support, typically do not increase physician loyalty in the long term. However, advances in technology offer a host of options to address recruiting and retaining the best physicians. These solutions include Customer Relationship Management (CRM) and data mining tools that allow business users within a healthcare organization to manage ongoing, mutually beneficial relationships with physicians that increase loyalty in the long term.

You can also view our webinar on the topic: ”Healthcare Reform & Physician Loyalty: What Can CRM Do To Support Accountable Care Organizations (ACO)?”.  During this presentation we covered physician loyalty and why it has become such a hot topic in light of healthcare reform and increasing trends in physician turnover.  Perficient’s Lisa Anderson provided a demo of CRM and how this technology tool can help hospitals increase their loyalty, and resulting referrals, from physicians.

You can view the slides below.  You can also view a recast of the webinar here: http://www.perficient.com/webinars/

See this slideshow on SlideShare.

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12 Things You Should NOT Do on a Portal Project

by on June 30th, 2011

Yesterday Perficient’s portal experts held a webinar entitled “12 Things You Should NOT Do on a Portal Project”.  The webinar was highly entertaining.  You can view the entire webinar here.

Considering the growth of social media, collaborative care, and patient engagement in healthcare, I felt it was important to recap the 12 things not to do so that healthcare organizations do not fall into these traps. 

#1 My Missing Homepage The portal team started out with a story of an insurance organization that was juggling multiple portal projects.  In this particular case, the developers of a latter portal project co-opted the homepage of the earlier portal projects.  This caused the homepage on earlier portals to disappear completely.  When juggling these portal projects, it is a good idea to set up a shared taxonomy so that this confusion does not occur.

#2 The Business Asked for it!  Each organization sees itself as unique.  Therefore, when considering their portal needs they end up building custom applications, which are often much more resource intense.  There are many “portal in a box” solutions available on the market.  Oftentimes, these out of the box solutions can be used to meet 95% of the business requirements you are looking for.  By starting with an out of the box solution, you can then add custom components where needed.  Your portal project will become far less resource intense as a result.

#3 Methodology for Methodologies Sake This one actually captures what I say time and time again: start with the business problem.  IT geeks love technology for technology’s sake.  However, it’s not very rational to implement expensive technology solutions simply because they are cool (although they most certainly are).  If you don’t lose sight of what is important, then the end result of Health IT will be highly functional for the end user.

#4 The Never-Ending Strategy It is good to start with a portal strategy.  The strategy sets the overall direction and approach for your project.  According to our pros, the strategy should prioritize the direction of architecture, content, governance, security, development, search, etc.  This can be put together within a 2-4 week roadmap.  A bad or overly complex strategy will actually slow down or inhibit the launch of your portal.  Focus on solving the business problem; don’t become a slave to strategy.

#5 I Built it But Now I Can’t Support It Technology projects can be complicated.  A portal project requires knowledge workers with skills in architecture, security, training, web technology, etc.  Some organizations choose to cut costs through minimizing the number of people resources they use to build or support their portal.  This can often be a recipe for disaster.  The problems that surface can end up multiplying the cost of the portal project well above the savings found through cutting corners.

#6 We Can Get a Big ROI from Portal Our portal experts highlighted a story of a company that wanted to cut time from their processes in order to increase ROI.  However, they implemented a portal project that actually added time to their processes and gave them a negative ROI of $2.3 million/year as a result!  The main issues were: 1) lack of strong technical resources that understood portals and 2) their portal solution lacked user experience capabilities.  Mitigating these issues would have informed developers of how end users would use the system, which then directs implementation.

#7 Is Best of Breed Always Best There is a time and place for both best of breed portal or the one vendor stack portal.  Stop debating and consider your needs.  Sometimes best of breed is best.  Sometimes the one vendor stack portal is actually best to meet your unique portal needs.  Match your requirements with the available options, and you will be fine.

#8 When Developers Can’t Develop Sometimes a portal administrator puts up a wall to developers.  As such, any time developers need to make a change they need to work through this portal administrator, which creates a bottleneck.  This is particularly the case when the portal administrator isn’t the best person for the solution at hand.  There is oftentimes creates stand offs between portal administrators and development teams during a portal project.  Decision making silos occur, and the parties lack insight into what the other is doing.  Everyone should work as a team.

#9 When Not to Use a Portal There are times when portal is not the correct solution.  Sometimes a “side-by-side” approach is best.  Side-by-side is an approach were portal and other complex applications live side-by-side.  Don’t use an overly complicated portal as a full interface when a side-by-side solution would be best.

#10 When Web 2.0 is 2.Much Once upon a time there was a company whose implementor decided everything should be done using Ajax.  This didn’t work out for them since their portlet simply served content.  According to our portal experts, any portlet that only servers content should never be implemented with Ajax.

#11 Infinite Loops on the Homepage Portal implementation team members can lay awake at night hoping their server doesn’t crash under the weight of resource overload.  The key to a restful night’s sleep in this case is testing. You should perform a series of tests to catch any and all possible errors that could cause a rogue portlet to bring your entire site down.

#12 Building My Own MVC Our portal experts told the terrifying story of an architect who felt that Java Server Faces, Spring MVC and Struts were not good enough so he designed and built a custom Model View Controller (MVC)  framework for development in WebSphere Portal.  All went well until he left the company.  You do not want a single source of failure.  As such, it is best to first look at what is available when development needs come up.

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Can Social Media Save Lives?

by on June 29th, 2011

I attended a webinar today entitled “Can Social Media Save Lives?”.  This webinar was organized by the HealthWorks Collective.  While a good portion of the agenda rehashed commonly used statistics about the use of social media in healthcare and the fact that there is still a lot of confusion about social media as a tool within a healthcare organization, I was particularly interested in the discussion led by Dr. Mark Ryan (@RichmondDoc), who works for the Department of Family Medicine at Virginia Commonwealth University Medical Center.

He started by pointing out that, prior to popular conception, “epatient” does not stand for “electronic patient”.  Rather, “equipped, enabled, empowered, engaged” are the correct adjectives to describe this growing group of patients.  These epatients use the internet and social media to educate themselves and others to enhance their health.  Dr. Ryan also pointed out that these epatients are enhancing healthcare for providers as well.  These patients are becoming involved in care.  They are asking questions of providers, and they are collaborating in treatment.  This is very much in line with the concepts spelled out in other efforts, such as patient-centered medical home (PCMH), accountable care (ACO), and participatory healthcare.

While an earlier speaker, who had spent time doing social media for Johnson & Johnson, advised listeners to create social media policies that reflect all laws and regulations and to train staff accordingly, Dr. Ryan rightly pointed out that there are no standards of use or official “best practices” for social media in healthcare.  Even the guidelines published by the AMA are not very useful.  The role of healthcare in social media is still developing, which causes much concern by the medical community.  He also cautioned social media users on the importance of privacy (for both the patient and the provider).  He stated that providers cannot practice medicine in a social media setting and advised that these social media platforms should be integrated with patient portals. 

Here is a list of potential healthcare benefits from social media that Dr. Ryan highlighted:

  • Changes the model for healthcare delivery (new platforms; patient portals)
  • Allows doctors to answer general questions and be a resource to the community for general topics
  • Helps patients find necessary resources
  • Provides a platform for healthcare advocacy
  • Becomes an importantsource for public health information that can be broadcast to a large mass quickly
  • Creates disease specific reminders can be set up for disease management (e.g., text messages directly from doctors can improve adherence and patient satisfaction for diabetes patients)
  • Connects social media into personal communication via a patient portal that will maximize social media’s potential

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Posted in Collaboration, News | 5 Comments »

Preparing a Healthcare Organization for Change

by on June 29th, 2011

As any CIO knows, any organizational change, badly managed, can lead to whining and revolt.  However, as shown in our earlier post, “How the Healthcare CIO Saves Lives” the benefits of successfully implementing IT initiatives like Business Process Management can be profound.  In many cases we are talking about the difference between life and death.  However, before we implement these life-saving IT initiatives we must first discuss how to successfully lead the charge for change. 

A recent article from Information Week provided some thoughts on instituting change that would not cause doctors and nurses to revolt.  In this article Anthony Guerra recommended: 1) developing a team that involves all key players in planning this organizational change, and 2) having one point of contact on that team that end users can reach out to when they are having issues.

This idea of creating a team to lead the charge is a great one.  Here are some tips:

Do Not Lead with an Army of One

Managing change without a team is failure waiting to happen.  Instead, create a cross-functional, multi-level team of stakeholders. Pick key “ambassadors” from across the organization that work directly with the processes under scrutiny.  By working with these ambassadors from across the organization you will get a good feel of the barriers in your way.  Positive water cooler conversations from these ambassadors can also help prepare the larger organization for change. 

Recruit C-Level Support

Unfortunately, the CIO cannot move this mountain alone.  It is important to recruit C-level sponsorship via executive membership across the organization.  Obviously, selecting those executives that manage the portions of the organization most impacted by the change is ideal.

Do Not Make Decisions in a Vacuum: 

This team needs to have a clear understanding of the business processes, information processes, and data needs of the organization.  Proactively seek outside information.  This not only helps evade group think, but can aid in increased adoption of policies and processes as well. 

Have a Single Point of Contact

Make sure that end users know the individual that they need to contact if they are having issues.  If the end user does not know who to turn to, then they will turn to everyone they know in the organization with their problem.  This increase of negative sentiment could lead your initiative towards failure.

Communicate the Change 7 Different Times in 7 Different Ways

Effecting successful change requires the team to coordinate how these change efforts will be communicated effectively across the organization so that everyone is on board.  Sending out one corporate-wide email often won’t cut it.  The “7 times/7 ways” method is very effective.  Communicate this new change in different formats: townhall, email, workshops, signage, etc.  Seeing these repeated messages will aid the organization in navigating this change.

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High-cost Patients, High-Tech Solutions: Why Taxpayers Deserve ICD-10 Compliance

by on June 28th, 2011

When the sickest 1-percent of patients are responsible for nearly 30-percent of healthcare costs (over $690 billion annually) everyone loses. Since millions of people will be joining Medicaid under the new healthcare reform, states must either be prepared to pay the price tag associated with high-cost patients or determine a better way to manage the additional costs.

If Medicaid programs continue operating at status-quo, taxpayers will be footing the bill for the millions of new Medicaid members. Without hefty tax increases and drastic decreases in funding to other social programs, the additional healthcare expenses from new members will result in many belly-up states. However, another option exists. Healthcare organizations can use technology to better manage patients. The American Relief and Recovery Act (ARRA) of 2009 allocated more than $30 billion in HIT incentive payments to healthcare organizations that invest in certified technologies to improve the exchange of healthcare information. If organizations take the bait, the outcome, amongst many other outcomes, will be lower healthcare costs.

Organizations that comply with the looming ICD-10 conversions mandated by the ARRA will have better data at their disposal.  Some of this data will be used to better manage care for high-cost patients and individuals who overuse, underuse and misuse healthcare.  But why should you, you being a taxpayer, care about healthcare data?  The answer is because as a taxpayer you rely on the government to provide social programs in a cost-effective manner.  To expunge every ounce of value from tax dollars, the US government mandated healthcare organizations become ICD-10 compliant by October 2013.

Compliance creates value for the taxpayer because the data collected will be used to better serve and manage care.  Therefore, the ability to lower healthcare costs for the most expensive patients, whose care is monopolizing tax dollars, lies in the hands of healthcare organizations nationwide.  It is a monumental time where legislation is driving down accountability within the private sector.  Healthcare organizations who embrace the changes and invest in HIT will be rewarded through government incentive payments and healthier bottom lines – these organizations will also reap the rewards of being socially responsible for driving down healthcare costs for citizens nationwide.  

Whether you are a decision maker at a healthcare organization in need of a technology facelift or “Joe the Plumber” each of us has one thing in common – we pay taxes. Therefore, as socially conscious citizens we should encourage and reward local healthcare organizations that invest in healthcare technology and comply with the ICD-10 mandate because it benefits us as individuals, as communities, as businesses and as a nation striving to have a first-rate system to serve a first-rate society.

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Posted in News, Regulatory Compliance | 1 Comment »

How the Healthcare CIO Saves Lives

by on June 27th, 2011

There are many benefits to Health IT, but when it comes to these business drivers there is one that leads the charge: increased efficiency.

The motivation to increase efficiency is on the lips of healthcare executives in both provider and health plan circles across the nation.  Controlling and being aware of the cost of care is important.  By including costs in the exchange of clinical information, providers can begin to understand the correlation between the quality of care and the costs associated with that care across the continuum.

It is just these types of efficiencies that drive government incentives towards a more connected healthcare environment.  From EMRs to HIEs and beyond, the Healthcare CIO is involved in a slew of activities aimed at providing increased efficiency across the organization.

Increased Efficiency Also Saves Lives

However, while driving efficiency reduces costs and makes for a much healthier organization, in healthcare greater efficiency also means increasing the health of patients that an organization serves.  Better efficiency facilitates treatment across all of a hospital’s facilities and helps a patient get well instead of experiencing a rapid decline in health that inefficiency can cause.

These cost savings, and increased health, ultimately come in the form of reduced readmissions, which is why HHS released Partnership for Patients back in April.  The partnership calls on hospitals to focus on nine specific medical errors with the goal of reducing readmissions by 20% by 2013.  These errors include adverse drug events, obstetrical adverse events, and surgical site infections to name a few.

Health IT can have an incredible impact on the efforts of Partnership for Patients.  In an article by Healthcare IT News, four hospitals were highlighted for leading the way in increasing efficiency around these nine medical errors.  As shown by these great examples, the key IT solution to these nine medical errors is found in Business Process Management (BPM).  BPM can help an organization by improving processes around dispensing and administering medications, post-surgical procedures, and a host of other processes that comprise care.  Healthcare systems that begin to address the question of efficiency through process improvement and enabling technologies will be able to control cost, improve margins and drive improved patient experiences.

In a set of future posts we will identify all of the ways that increasing efficiency through Health IT saves lives.  In the meanwhile, you can leave a comment below with some of your thoughts.

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Why the Healthcare Social Media Chatter Matters

by on June 23rd, 2011

Sometimes when I write about social media in healthcare I imagine a make-believe healthcare technology purist that I’ve conjured up rolling her eyes at me.  She scoffs at my adding to the zettabytes of digital data on one of the more “softball” technology topics.  What does social media have to do with “real” healthcare technology anyway?  I should be using alpha-numeric acronyms and drawing IT diagrams with lots of arrows of varying size.  This is healthcare technology, after all.  There are more important things to write about than social media, right? 

I answer such sentiment by saying that healthcare social media is one of the most important healthcare IT topics of our day.  Social media is informing and enabling rapid evolution both in terms of healthcare delivery and Health IT innovation in and of itself.  Why? While measures like data integration through 5010 and ICD-10 and reporting requirements through meaningful use are driven by government incentives and regulations, the move towards a more collaborative healthcare model is being driven by a massive and growing group of healthcare consumers popularly dubbed “epatients”.

This is a growing and powerful force that is challenging the traditional barriers between patients and their healthcare providers.  Approximately one-third of adults in the US are using social media to collect health information.  58% of individuals surveyed assume a diagnosis based on the information they gathered online. Doctors are modifying their ways of engaging out of necessity, and healthcare organizations are having to adapt their business models in response.  A blog post (written by Kelly Young) on Dr. Luks blog asked if e-patients were crossing “the line” when it came to altering their relationship with healthcare providers.  She adeptly answered, “What line?” 

Social media has been a game changer.  There are many opportunities for healthcare providers to become far more efficient using social collaboration tools, including many areas where they could save time, money and build stronger relationships with their patients.  These savings and creation of goodwill can begin while setting appointments and move forward to impact every area of care.  In a recent Healthcare IT News article entitled “Docs, patients ready for online tools“ the following facts were disclosed:

  • 95% of doctors and 81% of patients want to fill out medical forms online before an appointment
  • 1 in 4 healthcare providers that do not offer online tools say it is difficult to reach patients for communications about appointments and lab results
  • 1/3 of healthcare providers spend 3+ hours per day trying to follow up with patients 
  • 72% of patients complain about having to repeatedly fill out the same paper forms

ePatients have been making waves for some time, and providers and health plans are now adapting.  Last week at AHIP we discussed the rise of these healthcare consumers.  In discussions on ACO we discuss the changing role of patients within the care delivery model.  Healthcare providers are trying to keep up with patient sentiment in public forums.  Doctors are responding to the collection of healthcare information online.  Many are experimenting with a more cost-effective care delivery models replete with virtual visits and social media communication forums.  Health insurers are looking for better ways to communicate with members.  Leading healthcare organizations are now asking how they too can communicate with their patients in social media platforms through HIPAA compliant channels.  Software providers are hunkered down in their labs developing these HIPAA compliant and mobile technology solutions to meet demand.  Conversations about all of these topics and more are taking place right now in social media forums across the globe.

So, if you are searching for the prime channel to tap into all of those epatients that are transforming their role in healthcare, and the healthcare business models of both providers and payers as a result, look no further than the hashtags and status updates of individuals who have found their voice on social media.  Trust me, if you are not listening then there are plenty who will. 

With that in mind, I would like to send a hearty congratulations to all of those mentioned as top contributors to HIT social media on the list compiled by HL7 Standards.  It’s an honor that Perficient is named as the top organizational contributor to Healthcare IT conversations in social media!

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Posted in Collaboration, News | 5 Comments »

Lessons from this Year’s AHIP Conference

by on June 20th, 2011

We were at the AHIP conference last week, and as shown in our earlier posts, we learneda lot at this year’s event.  The health insurance industry is at a point of tremendous evolution, and there are a lot of factors to consider.  Here are a few of the key themes that we took away from this year’s event:

Health Insurance Exchange: Health Insurance Exchange was the early winner in terms of themes that dominated conversation.  On the first day of AHIP, many attendees opted to attend the Exchange Conference exclusively.  Many of the items learned will help health plans navigate the increasingly interconnected healthcare environment that we will experience in the days to come.  Here is an interesting article that came out during the conference on how health insurance exchanges require an ambitious infrastructure.

The Rise of Healthcare Consumerism: As mentioned under our Utilization Management post, the changing role of patients within healthcare is causing a lot of changes to business processes and the traditional way of doing business in the healthcare industry.  Patients are being invited into the design of their care, and there are cost efficiencies that result in terms of reduced readmissions and the like.  Terms like “mass personaliziation” that have been big in retail for years are now making their way into conversations here at AHIP.  Here are some of the sessions that addressed this trend:

  • Understanding the Consumers’ Decision Process in Purchasing Health Insurance
  • Healthcare Transformation: The Movement Towards Individuals; Personalized Medicine: Its Value Today and in the Future
  • Mass Personalization: Optimizing Consumer Engagements for Improved Health Outcomes

Impact of Healthcare Reform:  This is a big topic anywhere you turn in the healthcare industry, or mainstream news in general, these days.  It goes without saying that this was a hot topic at this year’s conference.  More specifically, data is becoming electronic and healthcare organizations are becoming increasingly interconnected under healthcare reform measures.  This has generated ongoing conversation around how to prepare a health insurance business for these changes.  Some of the break-out sessions that dealt with this topic include:

  • Re-Engineering the Health Plan Business Model to Succeed in a Post-Reform Market
  • Four Imperatives for Post Reform Healthcare

Accountable Care Organizations: Conversations about Accountable Care is alive in both the provider and health plan industries these days.  Health Plans are making sense of the accountable care model and the changes that will need to be made to their business model as a result of this healthcare reform measure are being considered.  There were many education events on the topic of ACO.  They include:

  • Creating Sustainable Accountable Care Models; Population Health: The Reality Behind Healthcare Reform
  • Delivery Model Transformation: How will Business Models change with ACOs?

Creating Efficiency Through Health IT: As predicted in our earlier post about the rewards found in the pain that is ICD-10, there was a lot of conversation about transforming an organization with “next generation” technology as a result of mandated reform measures.  Our own customer, BCBS of Massachusetts, summed this up very well in a video earlier this year.  These themes were addressed in:

  • ICD-10: More than a Regulatory Requirement, An Opportunity for Business Improvement
  • Leveraging Health IT: Maximizing Your Capabilities to Create Efficiencies

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Accountable Care Meets Analytics at AHIP

by on June 16th, 2011

We are in San Francisco this week at the America’s Health Insurance Plans (AHIP) Conference.  This is a great event, and there are a lot of themes being evaluated by the conference attendees.  One hot topic from our blog is how to create sustainable Accountable Care models. This Thursday late morning session was standing room only and shows the strong level of interest in ACOs.

The session by Deloitte Consulting had an interesting twist – live audience surveys using text messages to create real-time bar charts of the results. For example, when the audience was asked what was driving the interest in Accountable Care, 56% said Rate and Margin pressure, while 40% said it was Outcome based payment terms, and finally only 4% said that dropping Traditional Barriers was the driver.  The survey indicated that dropping traditional barriers like the creation of health information exchanges or increased pressure for transparency aren’t top of mind versus addressing increasing rate and margin pressures.

Another key observation by the speakers was that collaboration will be mandatory in order to manage episodic care between the plan, provider and member.  In order to move from the traditional fee for service model to quality-based episodic payments then a moderate level of collaboration is required between the three parties and that introduces a moderate degree of risk as well.  Communication needs to be bidirectional and outcome focused to manage costs while maintaining quality.

When the audience was surveyed on the best approach for accountable care from three possible choices, the results were equally surprising.  The Medical Home approach garnered 56% of the votes, while the Integrated System approach was 32% and Condition Specfic ACOs (diabetes, obesity, heart disease) scored 27%.  What was surprising was that a vote for the Medical Home approach said that AHIP attendees liked an open market approach with an educated consumer versus the Integrated System which would be more like a public utility, vertically integrated and possibly monopolistic.  The Medical Home approach popularity may come from retaining an aligned competitive environment that would help drive down costs.

The final observation about building a sustainable model for accountable care is that the approach must be based on a strong information management foundation including enterprise data warehousing, advanced analytics and data governance.  In order to track outcomes for judging quality and episodic care management, then near real-time, holistic and integrated information will be critical to success.  The speaker admonished the crowd: “You have to compete on analytics!” He went on to observe that there isn’t a single source solution today, however a roadmap must be developed for technology to support the new world of accountable care.

The time to have a dialog on this technology roadmap for ACOs is now – what do you think?

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Posted in Business Intelligence, News | 4 Comments »

A Fresh Look at Utilization Management at AHIP

by on June 16th, 2011

We are in San Francisco this week at the America’s Health Insurance Plans (AHIP) Conference.  This is a great event, and there are a lot of conversations going on among conference attendees.  One hot topic from our AHIP Trend Watch post is the pressure health insurers are under with regards to Utilization Management.

Utilization Management is generally defined as reimbursement restrictions from a health insurer for a medical service.  Utilization management takes three basic forms: 1) prospective or pre-authorization of service, 2) concurrent review, and 3) retrospective review after the service has been rendered.

Utilization management is often viewed as a form of non-price rationing taking the operational form of a denied claim or ‘redirected’ service. Utilization Management within healthcare insurers is under pressure from four fronts:

  1. Shifting focus towards healthcare consumerism: People want to shop for their choice of healthcare provider services, thus challenging preauthorization processes
  2. Healthcare insurers working to reduce administrative costs to meet government regulatory pressures:  This makes it important to find an easy way to manage provider service contracts 
  3. Pressing need to modernize legacy IT systems: This includes implementing more flexible service oriented architecture to allow for more automated business processes
  4. Moving away from paper: The shift from paper claims, scanned documents and faxes to electronic claims, email and electronic content management (ECM) systems 

Tackling the modernization of legacy IT systems is key to addressing all four sources of pressure.  Forward thinking healthcare insurers are “wrapping” those mainframe applications as web services that can be integrated into business process management systems (BPMS).  BPMS software allows the flexible management of case creation, clinical review, appeals, audits and communication with the providers.  In addition, these more automated business processes can be depicted in easier to use web portal pages that are tailored to the work process of the individual.  That same portal can review a case, examine the electronic claims, review documents from the ECM system, and pass cases for approval to managers. Newer BPMS software includes business rules and work routing that can escalate cases and, in some instances, provide the health plan member with immediate feedback.

Instead of viewing the rise of healthcare consumerism as a challenge to utilization management, there is an opportunity for a healthcare insurer to gain competitive advantage.  By automating Utilization Management groups, the health plan could offer concierge service to help their members select not only a provider within the plan, but one that really satisfies their health goals. By coordinating members into chronic condition management programs or wellness programs, the goal of reducing costs and utilization will be much easier.  Integrating information into automated workflows will speed up responses to members, thus increasing member satisfaction, too.

Finally, adopting business processing management software will yield greater business flexibility.  One of the positive side effects of modeling business processes is that all of the steps that utilization management must do today become visible, thus allowing the analysis of where redundant steps are taken or shortcuts are available.  The pressures to reduce costs and allow healthcare consumers more freedom can be the impetus for taking a fresh approach to traditional utilization management processes.  Don’t let your competitors get there before your organization does!

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