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John Bradshaw

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HIPAA and its Impact on Your Organization

I bet many of you have heard of HIPAA, but you may not realize its impact on you and your organization.  Personally, if you or a family member has been to see a physician in the last 10 year, you were presented with a HIPAA form to sign.  Professionally, if you work in healthcare, you surely have heard of it and hopefully have been through awareness training.  Even though there’s a training course in place, that doesn’t mean your organization is fully compliant.  For those of you that work for a third party that provides services to a healthcare organization, the potential impact to your organization is even more urgent.  So please read on.

The basic types of healthcare entities in the market are payers, or health plans, and providers.  Payers are organizations that offer health insurance, either through their own health plans or working with employers to support the employer in offering an employer-sponsored health plan.  More than 50% of the people in the US participate in an locked-computer-keyboardemployer sponsored plan.  As for the remaining Americans, 16% are covered by Medicare, 17% by Medicaid and the remaining 15% are uninsured.  I’m sure you’ve seen the news lately about the opening of the Health Insurance Exchanges, or HIXs.  Initially, the HIXs are targeting those that didn’t have insurance, either because the individual didn’t work for an employer that offered health coverage or due to cost.  Healthcare reform has made changes to ensure that everyone can obtain coverage and do so affordably, either through an HIX or your employer.

The term provider refers to all who deliver health care services to you and your family.  A provider can be your family doctor, local hospital or MRI facility.  Providers deliver health care services to you and, if you have insurance, interact with the insurance company to determine what your health plan will pay and what you as a patient are required to pay, such as a deductible and copay.

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Key Ingredients to an Enterprise Information Management Solution

EIM Gumbo

1 portion of Data Governance

1 portion of Data Warehousing

A stock of interoperability*

Culture, chopped up finely

Dash of patience

*Measured and added to the extent as needed.  Can be made up of a variety of means, manner and mechanisms to facility the move of data to the warehouse and information from there out to the plate in preparation for consumption

Preparation:

  1. cast.iron_.pot_.on_.stove_.istockMake a roux with Data Governance – let it cook for a good long while, it can’t be rushed and takes time.
  2. As the Data Governance is simmering, you can begin dicing up the Data Warehousing.
  3. Once the Data Governance roux is ready, mix in the Data Warehousing. Give the Data Warehousing a little time to get set up and going.
  4. Slowly begin to pour in the stock of interoperability, stirring to mix as you do.
  5. Throw in a dash of patience, adjusting to taste as the gumbo simmers.
  6. Let cook for 36 – 60 months, with a low initial temperature, gradually increased over time.
  7. You can begin tasting and sampling after 12 months.
  8. Prior to serving, add the Culture, giving it enough time to cook, add more over time as is needed.
  9. Enjoy!  And don’t be afraid to get creative once everything is well under way.

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5 ways OBI + BPM + Member Portal = Success

What kind of equation is that?  I can understand Member Portal, but OBI? BPM?  Well, OBI stands for operational business intelligence.  OBI is real-time, dynamic use of analytics that enables a service component to decide, based upon the information available, how to proceed in engaging with a stakeholder.  BPM, or business process management, refers to the defining and execution of business workflows.  Bringing the two together in a member (could be a patient) portal is a formula to success.  All health plans today use a member portal to provide basic, on-demand services.  Typically these portals include the ability to review past claims, search for a provider, plan documents describing their benefit program, find industry medial reference databases, enroll for benefits, fill prescriptions, view FAQs about their benefits program and even view and manage funds deposited in high-deductible savings accounts.  But, as stated, access is on-demand.  The members need to be well educated on the benefits consumption process to help themselves.  In many cases, most just stumble through the process.  To make matters worse, most of them don’t interact with our benefits site beyond the annual election process or, most importantly, when we have a need.

The time is right, and the solutions are there, for health plans to enhance the member services by moving from a passive, on-demand model to an active, assertive one.  Doing so will increase member satisfaction, important for retention with the advent of Health Insurance Exchanges (HIXs) and consumerism in the benefits insurance marketplace, decrease the cost to serve, and increase the productivity of the health plan resources engaged in their services operations.  Leveraging OBI and BPM, delivered through a mobile-enabled platform, is the way of the future!

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The Exchanges are coming, the Exchanges are coming!

Are you making the most of it?

Yes, I said Exchange, but will refer to them as Health Insurance Marketplaces (HIM).  I know many have been working to get ready for the October 1st open enrollment, but have you been doing everything you can?  In the past, sales of individual policies haven’t amounted to more than a single digit percent of the population and your book of business.  With the opening of state and the Federal HIMs, everything changes for the individual policy product, moving it from “step-child” status to mainstream.  All are focused on this and have begun soliciting, at least in the manner their respective exchange allows, and getting ready to service this new channel.  While all eyes may be on the rollout of the HIM, the real opportunity for participating payers is on how they engagement with these prospective customers, pre and post-sale.

HIMs provide for the external event necessary to get the internal support and commitment (financial and otherwise) to take a way of doing business and move it to the next level.  There are two practices that are candidates for this step change.  The first deals with engaging and selling to this new channel.  The traditional approach, and NewWayGray1subsequent cost to acquire, has been mostly indirect, working through brokers, consultants and agents, employer HR, and state governments.  The apparatus and effort have substantive costs and a lengthy sales cycle.  Making things more challenging, retention isn’t assured by satisfying the many members, but the decision maker and the broker/agent.  So what’s the opportunity?  Well, you get to really do marketing; direct consumer marketing in fact.  As such, you need to rethink and revisit how you market, sell and service your products to this new channel.  Doing so requires a new approach, with the use of a Customer Engagement Platform, supported by content management, digital marketing, robust CRM capabilities, the ability to target consumers across a whole spectrum of means and devices, and the need to identify the impact to the current operational norms.  The last item involves the detailed review of standard operating procedures (SOPs) and basic concepts.  For example, a lead or prospect is not a member, and as such, you can’t depend on established member SOPs and systems.  This type of consumer engagement falls into a new area we refer to as Connected Health.  In the world of Connected Health, it’s recognized that the new norm for engagement is typically via the web, internet, smart phones, PCs, social media outlets, texting and other devices.

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Healthcare Reform: Payers – HIXs and Eligibility

In healthcare, it’s a common occurrence to find your organization having to make an investment, unplanned in many cases, in order to comply with a new regulatory requirement due to Health Reform.  When faced with a new compliance need, I have heard many wistfully ponder the question of ROI, yet are already resigned to another initiative to add to an already burdened organization.  What I then help folks understand is that you can get a ROI on this “required” investment, but it won’t be easy and it’s not obvious.  The answer comes from stepping back from the specific requirement, reviewing how the impacted part of the business runs today, analyzing the changes needed and examining how the requirement could be a catalyst for something bigger.  Most of the time, the focus is on the individual activities and tasks performed today and how they need to be tweaked, new steps shoe-horned in, an extra report run, etc.  Our typical response mode is to focus on the micro and don’t rock the boat.  By stepping back and examining the greater context or macro view of business activities and processes which will be impacted by the regulatory change, the organization can do two things.  One, comply and two, by expanding the focus, and yes, investing more, effect a longer term change that improves service levels (customer satisfaction) and reduces the cost to serve, effectively generating a return to offset that dreaded investment.

To help illustrate this, let’s focus on an effort underway by the Payer community to prepare for the forthcoming Healthcare Reform Health Insurance Exchanges (HIXs).  A primary engagement point between the payers and the HIXs deals with eligibility and premium information.  For any payer, a common daily activity is the receipt and handling of eligibility data from their many clients, particularly employer health plans.  While the 834 does exist for this very purpose, the complexity of the transaction, along with the various sources, such as HRIS solutions, HR staff, 3rd parties, etc. have led to a myriad of formats and mechanisms to facilitate this exchange.  Typically, these many feeds will either go directly into the underlying claims systems that support the membership in question or through a conversion process that spits out a proprietary eligibility load file or an 834.  This conversion process is somewhat of a one off with each client/feed, becoming a separate job that must be run, trouble-shooted and maintained.  Many are reacting to the HIX challenge by just setting up new jobs, thankful that the HIXs will be using 834s and trying to figure out the use of the 820 for the premium.

So what’s the broader or macro view and opportunity here?  In most cases, the payers are using a complex and expensive set of services set up years ago that focus on only EDI transactions.  Again, the opportunity that has presented itself is one of being able to step back, look at the broader context and, albeit a greater investment, drive change in how the organizations handle transactions in general.  As many payers wrestle with the need for greater access to, and accuracy of data, they are looking at establishing Data Governance, Master Data Management, ETL platforms, Data Repositories, Data Warehouses and delivery mechanisms.  An enabler to the aforementioned is the deployment of a data and transaction backbone, an Enterprise Service Bus (ESB).  And here’s the link: ESBs can not only support the organizations data consumption, but it can handle the operational transactions, both internal and external.  Furthermore, abstraction can be fully supported, meaning that a standard is developed for introducing eligibility data into the transactional platforms that consume it.  The ESB would accommodate the knowledge needed to interpret the inbound side of the 834 or 820, transforming it per established business rules and pushing it on its way to one or more destinations.  The beauty of such a setup is that it can be done incrementally.  In other words, you don’t need to change everything out at once.  The new and the old can co-exist, while migration occurs.  The organizations commitment up-front is to establish the new foundation and implement first those changes driven by the regulatory requirement.  An added benefit is that you tend to end up with a single interface into the transactional platforms for each core transaction and/or set of master data.  So, when it comes time to upgrading the underlying platforms, you have a minimal number of interfaces to worry about.

Given the multitude of offerings in the market today, any payer organization can do the above.  By multitude, I mean solutions for any budget and varying complexities of environments, along with many of the traditional technology stacks, such as IBM, Microsoft and Oracle.  So, if you’re willing to step back and look at the broader opportunity, a change driven by regulatory requirement can be leveraged in a way that benefits the company, the customers and, over time, provide the return you seek.

News Flash: Healthcare Reform Is Working (with some help)

I recently read an article in the NY Times talking about an “unexplainable” sharp and persistent slowdown in the growth of healthcare costs.  It has been followed by others, such as this one from USA Today, that have begun attempting to shed light on the reasons why.  Contrary to the partisanship rhetoric from our lawmakers, change is occurring and we’re heading in the right direction.  Healthcare Reform (HCR) is working.  I’ll talk about the “with some help” later.  The challenge with HCR is that it’s very large, complex and the value the nation derives from it is the sum of all its parts, such as Accountable Care Organizations (ACOs), Meaningful Use, ICD-10, enhancements to HIPAA (not to mention giving it some teeth and putting Business Associates on notice [page 5566, column 3, first bullet]). Also to consider are changing reimbursement schemes that are moving away from the fee-for-service to bundled payments focused on quality and outcomes, Health Information Exchanges (HIEs) requiring providers to share records and avoid duplicative/unnecessary tests, upcoming Health Insurance Exchanges (HIXs) that create a more affordable way to buy health insurance, driving the provider community and EMR/EHR software houses alike to more broadly use technology that not only focuses on each encounter, but looks beyond to the continuum of care for the individual and the population.  With this longitudinal view comes a focus on the quality of care, driven by both the incorporation and reporting of required quality measures, but also through having readily available information.  In addition, with much of the clinical data now in a transactional system and “structured,” it can be leveraged for decision support or business intelligence, both tactically at the point of care and strategically by driving investment and improvements in care.

This positive change is catching many by surprise.  Some have continued down the party path, for example, the  recent decision to not participate in some aspects of HCR by North Carolina, while others, such as Gov. Rick Scott of Florida, have done an about face.  The divisiveness has been around Medicaid Expansion and Health Insurance Exchanges (HIXs).  For the latter, if the state will not establish an HIX, the Federal Government will and they will control the review and “publishing” of Qualified Health Plans (QHPs) to be offered to each state’s population where there isn’t a local or regional HIX.  For Medicaid expansion, the Federal Government will fund the first three years, then revert to 90% for the next seven years.  That’s a great deal of money for the states to leave on the table and 10 years is a long time.  Again, the challenge and arguments against are looking only at the specific components and missing how they fit in with HCR in general.  Each piece has a role to play.  There are so many components to HCR that trying to measure the performance or impact of a specific one is not a good indicator of what’s going on overall.

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Why Do Many Health IT Projects Go On Forever? Here’s your answer

I guess I could’ve used “fail” instead of “go on forever,” but I chose to use the latter here for a reason.  For smaller initiatives, you occasionally get the former, but as is so often the case with those large enterprise endeavors, it’s the latter.  I’ve seen this occur time and time again, a couple of which I’ve been able to “rescue” myself.  Efforts that should only have taken a couple of years, are taking so long that no one ever remembers when they actually began or will end (if they ever will).  And, don’t ask any questions about budget or ROI!  To me these extended efforts become an exercise akin to banging ones head against the wall; you would think it would become so painful as to compel folks to stop just because of that.  But no, they are afraid to stop, so they continue.

I’ve listened to the stories of these efforts over the years, some currently underway, from across the Healthcare industry today, in both the Provider (EHRs) and Payer (Claim platforms) space (including for both, Portals, BI/DW, Data Gov, MDM).  In a number of cases, I’ve had the opportunity to observe and question folks associated with the efforts.  Based upon that and my own experiences, I’ve come to a conclusion as to the why.  It gets to ownership.  No one in those organizations that were/are getting nowhere fast feels that they own the effort, at any level.  There are many who are burdened with or responsible for it, but don’t see themselves as actually owning it.  When you’re burdened with something, it tends to become personal or individualized; it’s heavy, weighing you down and saps your energy and strength.  When you feel you own something, it becomes a source of energy, is enlightening, there’s excitement and compels you to action.  Now, imagine the impact each effect has on a large group of people trying to collectively deliver on enterprise-wide change.

Don’t misunderstand me, the feeling of ownership alone won’t get the effort done, but it provides the nexus or core from which the various disciplines, management skills and efforts needed to take an initiative from beginning to end radiate from.  This ownership will transcend the vertical or hierarchical way we typically organize ourselves as well.  Keep in mind that the many business processes executed every day to deliver goods and services to your customers cut across the organization.  There is no such thing as an IT initiative; there are only business initiatives with the requisite ownership and involvement from the organization.  This can be particularly challenging when you utilize help from the outside, but even then there must be folks from within the organization actively involved and owning the effort.  Feeling ownership and being part of a successful effort, leads to the development of pride.  Pride reinforces the feeling of and desire for ownership and, collectively, can enable the organization to tackle anything.

Providers and the Adoption of ICD-10

There are two areas of focus in the ICD-10 conversion, each of which must be remediated/completed by October 1, 2014.  Our initial thoughts, urges and efforts are towards technology or those systems that we must now use to do our jobs.  Said another way, we need to update/upgrade the transactional systems, applications, and data repositories we use to conduct business and exchange transactions with our various business partners.  This approach is typical.  Dust off or complete (the latter in most cases) an inventory of all impacted systems, vendors, reports, databases, files, etc…  Review the lists to determine the impact, work with vendors, and deploy updated versions of software and so on.  Not necessarily the easiest thing to do, but we’ve all had to do this multiple times in the past and the IT folks will take care of it.  Wait a minute you say!  Backup, I just covered a great deal of ground too quickly on something that can weigh heavily on most organizations, given everything else going on, to handle.  You’re right, I could devote blogs to just this topic alone.  But I think that’s the easy part, or at least it should be.

The second area of focus, and the one of greater impact and importance, is that which covers a provider;s standard of care, clinical document standards and practices employed by its healthcare professionals in the delivery of care.  It’s that which we have deployed technology to enable!  What is captured in patient records and clinical documents today is driven by what’s needed in order to submit for reimbursement.  Healthcare Reform has something else in mind, something longer term.  We’ve begun the effort to turn the Titanic away from an instance of care focus to the longitudinal or continuum of care and the accompanying outcome.  I would challenge each provider to examine their standards and to compare the current requirements for documentation of an encounter or patient services against what will be needed to adequately code a claim for ICD-10.  I would be surprised if more than half the encounters coded to a bill in a hospital today under ICD-9 will have sufficiently detailed records to do so under ICD-10.  The current “system” has been unduly constrained around the ICD-9 code set due to its longevity and focus on the here and now.  Very few healthcare professionals can recall anything other ICD-9, nor the challenges that were experienced when it was adopted so long ago. (more…)

Health Plans – Are you at Risk?

If you’re a Health Plan that doesn’t periodically “calculate” and assign risk to members, you’ve put yourself into a tight spot.  This is a foundational activity, which drives care management and planning for your member’s future utilization.  For capitated or fully insured offerings, this is a critical step in rate setting/premium determination.  For self-insured plans, you can create value and goodwill by enabling your customer to adequately plan for next years spend.

You Need to get One

If your organization doesn’t currently utilize a risk methodology, I would suggest you add the effort to your prioritization list, placing it at the top.  Even for those that do calculate risk, but through a 3rd party, I would strongly suggest bringing the activity and, more importantly, the knowledge, under your roof.  There are a number of “systems” or methodologies in the marketplace, I’m partial to the Johns Hopkins Adjusted Clinical Groups® (ACG®) System.  Its member focused, can be used for events underway, is predictive and provides equal visibility to the healthy members.  As for input, the mechanism should intake paid medical and pharmacy claims.

Having a robust member risk mechanism in place can enable more than what I mentioned above.  Use of a risk mechanism today is typically specific to internal processes and employees, where each employee has been trained to react to/leverage an indicator or marker in a prescribed manner.  The innovative use cases, value-generating opportunities, are those that integrate the use of the risk system into stakeholder Self-Service and pro-active services.

Impact of Social Media and Mobility

Over the last decade, portals have enabled the extension or “exposure” of certain business processes to stakeholders for self-service.  Many seem to prefer helping themselves, providing the site is intuitive and easy to use.  More recently, the explosion of smart-phones/mobile technology has markedly driven the desire and demands for both this and information on ones self.  This preference, for indirect communication, can be effectively leveraged through the use of a risk system.

Portals and Apps can be dynamic, driven by the members risk profile.  Content and tools helpful to a diabetic could be seamlessly incorporated into the member’s experience.  If recent claims and prescriptions point to an escalation from a primary care setting to that of a specialist, a list of nearby providers could be “pushed” out to the member, along with information and services dynamically added to their site/app.  As events unfold for a member, a “fog of war” can engulf them.  Through this connected experience you have the opportunity to provide them a checklist, recommend dos and don’ts, a guide to care, again done dynamically.  Another example deals with duplicative activity. If a battery of blood tests was performed by the PCP, which the specialist will need, you can facilitate coordination of care by noting that need.  By noting such in the checklist, you can enable the member in managing the costs by making sure the specialist makes a request of the PCP.  Even better, this is where a PHR can come into play, automatically initiating the request to the PCP.  Some of the more robust risk systems will include indicators on care resource utilization and level of coordination amongst providers.

Benefits and Opportunities

As you think about it, the possibilities are endless for incorporating the results from a risk management system into self-service and pro-active stakeholder systems.  An important result of doing so changes the member’s experience from one of being a pinball amongst providers, to one of being in control and on a deliberate path to a positive outcome.  The financial impact on the Health Plan is equally positive, spending is as needed, early intervention can deflect certain members from an event, or at least reduce the severity, the individual and/or employer groups are satisfied with the plan services provided and you retain and grow your business.

Implementation Challenges: What is BI?

A common need and challenge experienced by many organizations in the delivery of a BI solution is that while the desire for information is great, it is difficult to get those with the desire to articulate what their need really is.  This can include what they plan do with the information once they have it, what’s the value to be derived by having access to the information and, most importantly, what exactly is BI?  Let’s start by talking about what BI isn’t.  BI doesn’t include mandatory and best practice reporting typically driven by enterprise applications, such as legal, regulatory, financial and operational.  It also does not include the delivery of KPIs (Key Performance Indicators) which can provide a quick barometer or reference as to on-going versus expected performance.  I’ll refer to Reports and KPIs collectively as “Reporting”.  Reporting is all about displaying what’s normal and known, in other words, what’s “in the box”.  Then there’s “Analytics,” a step beyond Reporting, is for those organizations that wish to slice and dice the known or “in the box” data, typically driven by the definition of specific use cases.  Analytics can help bring clarity to anomalies seen in reports and KPIs or to evaluate the outcome of certain defined situations.  Analytics definitely benefits from the pursuit of BI, but is only a waypoint along the journey.

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Claim System Replacement and Consolidation Best Practices

Nothing is more impactful, engaging and notorious for a Health Insurance Payor than the replacement of their Claims platform or consolidation of many into one.  For those contemplating such a move or already in the throes of one, here are some thoughts around “Best Practices” to make the effort successful.

Data Repository

To facilitate the transformation of claims from one platform to another, a data repository should be used.  This provides for the establishment of a common information model and layer of abstraction between the source and the target.  This allows for ETL logic to be developed for each source and the target platform just once.  The use of a repository provides the opportunity for the development and application of the complex transformation logic and business rules required to convert the claim history and other information to something consumable by the target.  In terms of volume, claims history is the largest data set.  Typically 12 to 18 months of history is migrated, primarily to provide for duplication identification and allow for adjustments.  As one system will record the adjudication results differently than the other, for example key reference data, such as providers, eligibility, networks, plans and group structures, logic is leveraged to translate the history to conform to the design and function of the target platform.  The use of the repository provides for a more efficient, iterative effort as the transformation logic and business rules are developed and tested.

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I Need Data, Now!

This is a topic I touched on a couple of months ago in my blog EHRs, Analytics, Utilization and Population Health.”  Health Systems have been on a tear over the last several years with the deployment of technology to enable the transactional or tactical execution of business activities and delivery of care.  With the diversity of the business process needs, no one solution is able to meet them all.  This drives a requirement for integration, with a flurry of activity around hooking one module up to another, say bed monitoring and the EHR.  The “hook-up” is, typically, point to point.  Organizations are now wanting to, being compelled by legislation, best practices, management needs and nearing the completion of EHR rollouts, deliver analytic solutions or Use Cases built on a collection of data, sourced from these many business process applications.  What they’re now faced with is the effort to “get” the data from a dozen applications, which when done in the point-to-point context, could take 12 months of effort.  So much for a timely response to a need!  What to do?

Break the Vicious Cycle

To be able to respond to this continually increasing demand for timely access to data, Health Systems need to construct a service that can expedite, facilitate and manage the sourcing and sharing of data.  This effort is not without its challenges; while the concept is simple, the execution is not.  The underlying technology foundation needs to be able to “expose” the various business process applications or producers, providing access to the data contained therein that has been deemed as needing to be shared.  The act of consumption can be a single transaction or a large collection of data representing a diverse set of activities that occurred over time.  Again, the service would need to be able to accommodate and respond to the characteristics of each request.  As for scope of use, such a service would handle/respond to any request, as long as at least one of the endpoints existed within the context of the Health System.

Governance is Key

Data Governance provides the background on which the service and all data utilization can occur.  Two basic elements are critical to the success of the service.  The first is abstraction.  The producer and consumer don’t really care about the other; each needs only to know how to “talk” to the service.  As long as they can do that, an exchange can be made.  The second revolves around the use of a common dictionary.  For the exchange to be completely successful, the data element or collection of elements contained within the exchange needs to understandable by the consumer, and if the exchange was in response to an original request by the consumer, the consumer needs to be capable of asking the question appropriately.

The Long-Term View

The effort to establish a service as quickly presented here requires an investment in time, money, resources and a willingness to temporarily keep at bay many of these major data usage and analytics (ie., integration) requests that are beating at your door.  The short-term effort is great and painful, but the long-term impact will generate an ROI many times that of this initial investment.  The initial effort should focus on the necessary technology foundation, governance, management, education & awareness and the exposure of common/frequently utilized producers and their oft-consumed data elements.  Moving forward, through the work on new initiatives and a systematic re-provisioning of legacy, point-to-point exchanges to the service, the breadth and depth of data elements available for consumption will quickly grow.  This richness will provide for a quicker delivery and lower cost for each successive use, not to mention being able to say “ok”, when someone asks “I need data, now!”