Perficient Healtchare Solutions Blog


Posts Tagged ‘clinical business process monitoring’

Member-centric Care: Not without Business & Architectural RoadMap

If I had a dollar every time an Enterprise Architect said, “I have a Road Map,” and handed me the future state IT architecture (which is 5 years out) and proceeded to verbalize current to future IT while I madly wrote every word down in preparation for a Business Transformation Session to prioritize/re-prioritize initiatives, well you get the general thought here.  Not the way to be doing things.

The whole industry is going through business and IT transformation; however, Road Maps are never complete, unless someone is accountable for these deliverables (See

How can the business prioritize initiatives without a road map for understanding the IT implications… better yet, how can the business reprioritize initiatives without understanding the IT impacts? This has always baffled me.  Has it bothered you?

Visions have to be documented in many forms and various levels of details for the appropriate audience.  One size future state IT architecture does not fit all.

What are your thoughts?

Member-centric Care: Open source to the rescue?

A must read from my colleague, Martin Sizemore, entitled, “Is it time for open source in healthcare?”

Wow! This Business/Process with system enablement person, me, can understand this architecture stack.  Yes, now more than ever we need open source.

Prototyping Open Source for testing ICD-9 to ICD-10 with on the fly remediation before going to production in a collaborative environment with Payer and Provider.  There’s an interesting thought.  What are your thoughts?  It is ok to let me know that I have exceeded my knowledge on this one.  That is, I have gone too much into IT and need to stick to the Business side of things.  Glad to have Martin as the expert.

ICD-10 Revenue Neutrality Will Drive Collaborative Testing

I was reading my collegue Mike Berard’s blog, on ICD-10 Revenue Neutrality: A Strategic ApproachWe have discussed the importance of testing before production between Payer and Provider (e.g., Physicians and facilities). In his 2nd to last paragraph Mike proposes the following:

“The reality is that Revenue Neutrality verification is still subject to the availability of a Claims and Benefits test environment that will mirror production but accommodate GEMs and reimbursement schedule refinement on the fly. Does this mean that organizations will be subject to an infrastructure investment that also mirrors production? And will the test environment be subject to the same change control rigor of the production environment? I wonder if we have enough “maintenance widows” to support the number of changes to Claims and Benefits systems’ application logic before we know what changes to make the GEMs and reimbursement schedules…”

Based on my experience, I am not seeing Payer’s Business and IT departments addressing testing environments for Revenue Neutrality.  What is your experience?

I can see that Revenue Neutrality is being considered the end of the process so not much attention is being placed on it at this time.  Everyone is in ID and Stratification Mode.  However, as a process person, the end of the process is what drives the beginning of the process.  All critical information is gathered and tested at the beginning of the process to ensure the end-of-process can be completed and successfully reported.  If we are not testing ICD-9 to ICD-10 all the way through the process for Payer, Provider, and Member neutrality before we go to production, we must take a step back and revisit our Strategic Approach.

Mike concludes with the following:

“Revenue Neutrality may have an initial focus on billing and reimbursement based on clinical accuracy in procedural coding, but will ultimately depend upon remediation of information systems and close collaboration between the payer and provider for ongoing refinement of reimbursement contracts.” These are hand in hand with a Member’s benefits and out-of-pocket expenses for ICD-9 to ICD-10.  This should be tested and certified for our patients/members prior to production.  Otherwise, we are not member-centric.

Payers and Providers need to reengineer their processes to ensure remediation on the fly after going into production for Member-centric care with ICD-9 – ICD-10. Michael Hammer would not be very pleased with our reengineering efforts for member-centric care without remediation processes once in production.

What are your thoughts?

ACO – A Brave New Enterprise: Are you ready?

Racing towards an ACO and Population Management this year is a huge challenge.  A new enterprise platform is a must for an ACO to coordinate the changing of Provider and Payer processes and behavior not to mention the Shared Savings contracts which require new measurements and reporting: a shared dashboard.  Check out Martin Sizemore’s take and solution for this Brave New Enterprise.  Also, how are you going to leverage Cloud Technology?

During my years in consulting I have had the opportunity to work at a large local telecommunications carrier who wanted to get into long distance; thus, they had to open up their systems and serve competitive local exchange carriers.  Just 15 years ago the telecommunications industry faced a Brave New Enterprise.  Just as a local carrier had to go through third-party review and regulatory oversight, we now have a similar situation facing the ACOs.

The partners of the ACO need to start now on formal Enterprise User Group.  Yes, we are talking establishing weekly status meetings with all parties and a formal change request management process for the ACO.

What if multiple Providers want to change the flow and/or data extraction from/to the Brave New Enterprise?  This should be discussed by all users of the enterprise and prioritized in the appropriate release.

Changes will need to be fast and the ACO will need to follow an Agile w/iRise BPM.

Do you find it exciting to think of the Brave New Enterprise without the chains of a traditional SDLC?  Think of the mobile applications that can be put in place.  This white paper can help you to learn more.

The ACO BPM needs to be established.

Change requests will not be for just the Brave New Enterprise system, but will include process as well.  Think big.  The Telecom industry had to do so and it took years and lots of lessons learned. Avoid repeating the same mistakes since we do not have the time to re-invent the wheel.  Leverage whatever you can.  For example, Lesson Learned:  Start sooner rather than later….build with anticipation to manage changes to processes and systems in a formal consensus building environment.

What are your lessons learned from building and managing a Brave New Enterprise with parties that have to transition to a Brave New Relationship?  Do you have other industry comparisons to the Healthcare industry of today?

Member-Centric Care: Are we enabling the Next Generation of SMEs?

A struggle for the Payer/Provider Industry is how to prepare the next generation of Subject Matter Experts (SMEs).  Now more than ever you need the experienced Medical Directors, Clinicians, and Non-Clinicians on your multiple #1 initiatives.  Are you preparing your next generation of SMEs?  Yes, you do need the 20–25 years EE on the project team; however, you need the next generation of SMEs on your initiatives to be provided not just responsibility, but authority and VISIABILITY to the leadership team.  If you are placing all the responsibility on the well deserving EEs (which I say I am not worthy of them) who are eligible for retirement in the near future, you are missing the opportunity to establish, mentor, and enable the next generation of SMEs.  This is a wonderful opportunity to encourage knowledge transfer from Direct/Manager to Lead.  It is not easy for the experienced leads have to deliver on multiple #1 initiatives in reduced time frames with new technology and often do not have time to complete knowledge transfer (HINT: Ask for Help and Delegate).

The solution:  Now more than ever CTI/CIO/CEO needs to make sure that experienced EE SMEs are aligned with the next generation of EE SMEs.  They both need to be part of the team.  This will assist the experienced EE to delegate leadership of one or more #1 initiatives.  The next generation of EE SMEs needs the opportunity to present the status of their projects to leadership.  It is a learning process to document and present strategic vs. tactical updates to leadership in a concise time frame.  Staying up with technology and what is or isn’t working for the Healthcare industry really needs to be placed with IT and off of the business.  Even though businesses expect that SMEs are all knowledgeable of IT, it is just too much for any single business person to adequately cover business and IT in this rapidly changing environment.  What could happen is you may have a very experienced EE SME who has gone from being a Business SME to a Business/IT Generalist.  Has this happened to your team?  Are you on a team that has transformed the SME to IT/Business Generalist?

If you feel you are in this situation (i.e., low utilization of next generation of SMEs and overload of IT on a Business SME), then here is how you could leverage a Healthcare Consulting Practice.

  • Bring in a Business Solutions Architect
    • Sits on the business side and reports to the business
    • Healthcare (i.e., Payer/Provider experience) and IT experience (e.g., IT Architect)
    • Responsible for staying up on all IT industry best practices and changes in Healthcare
    • Responsible for delivering #1 business initiatives into a detailed architectural Road Map with the Payer/Provider IT practices (e.g., Enterprise Architect)
    • Responsible for transferring business and IT knowledge to the next generation of SMEs.  This could mean actual one hour per week sessions for planned knowledge transfer
  • Bring in a Healthcare Business Analyst that can flex to Systems Analyst
    • Sits on the business side and reports to the business/IT
    • Healthcare and Business Analyst experience working with System Analysts in translate the business “what” to system “how”
    • Responsible for capturing Business Requirements in a new BPM Methodology (e.g., Agile w/iRise BPM Methodology)
    • Responsible for transferring knowledge to the next generation of SMEs and Business Analysts
  • Bring in a Healthcare Systems Analyst to flex to the Business Analyst
    • Sits on the IT side and reports to business/IT
    • Healthcare and IT Systems Analyst experience working with Business Analysts in translation of business “what” and system “how”
    • Responsible for capturing System Requirements in new BPM Methodology
    • Responsible for transferring knowledge to the next generation of System Analysts
  • Bring in a Healthcare Project Manager to ensure the a detailed Business/IT workplan is completed and managed (NOTE: Avoid the high-level milestone plan to record IT hours only)
    • Sits on the business side and reports to business/IT
    • Healthcare and Project Management Experience (i.e., packaged solutions, business transformation, legacy systems, release management, etc.)
    • Responsible for PM of issues, change requests, and action items are following the client’s methodology/system (NOTE: Client PMs have portfolio responsibilities and are unable to stay on top of day-to-day PM)
    • Responsible for transferring knowledge to the next generation of Project Managers

Now you have a single team with clear responsibilities, reporting and transferring of knowledge to the next generation of SMES and taking the load of the IT industry knowledge off the shoulders of the well deserving EEs who are driving multiple #1 initiatives.

Member-Centric Care: Are we working on the correct priorities?

In my previous blogs, I asked if we were missing a key player in member-centric care and then provided my opinion. Here is a recap of questions and answers I discussed, as well as some new points:

Are we, business and information technology professionals, clinicians, and non-clinicians, working on the correct priorities for member-centric care that are facing our core team (i.e., payers, providers, facilities, third-party vendor, regulatory agencies, and members)?

  • It Depends — I love this one, don’t you?
  • The priorities have not been ranked by the business for IT.  Every priority seems to be #1, because they are #1.  As consultants, we need to assist the business in ranking their priorities based on the slightest variations of cost and SPEED TO MARKET.
  • We need to complete IT Transformation without the chains of traditional SDLC to meet SPEED TO MARKET:  The solution should be Agile w/ iRise for BPM.
    • See Perficient BPM Blog
    • At my most recent engagement, we worked within the client’s IT SDLC that did include Agile with a huge approval process and formal training. I’m not sure how iRise can be implemented within a big Payer without going through a tedious SDLC review committee, formal training for the team, etc. (i.e., there goes 6 months before the first kick-off meeting).  The client will continue to be Traditional SDLC unless the CTO/CIO/CEO bypasses the formal process and prototype Agile w/iRise following a formal BPM methodology.
      • Rapid changes and re-prioritization with monthly implementations are required NOW for the business to transform to Member-Centric Care.  IT must also transform as the business transforms.  One cannot happen without the other.
      • For the successful Payer and Provider to work on the correct Member-Centric Transformation Priorities, they must make IT SDLC transformation a #1 priority.
      • The successful Payer and Providers will be working to correct changing priorities in build if they allow IT to transform its SDLC to support BPM with the RIGHT tools.
      • What are your thoughts and experience of working within a traditional Payer and/or Provider to Agile w/iRise?
      • How do you add many off shoot links to a traditional SDLC?
        • I am familiar with the solution and experience of working with Payers and Providers to achieve rapid development once the links are set in the client’s traditional chain.
        • HINT: The only way for the above to be implemented is through knowledge transfer from the consultant to the client’s team members and leadership and support the client in their adoption from top down.  Employees are the stars that align and make HUGE transformation from in traditional environment
        • If you are a CTO/CIO/CEO for a payer or provider, what is your experience?  Is it possible?  How did you set consultants and employees to be successful?
        • If you are a Payer or Provider that is on the business and/or IT team leading the transformation to Member-centric care, how is it going?  What are your lessons learned?

Member-centric Care: Missing a Core Team Member

In my last blog post I asked if we have missed a core team member in member-centric care. My answer: In Sales there are the Health, Life and Supplemental Insurance Agents for employers and members that are responsible for mentoring members on plans, eligibility and benefits as well as understanding claims.

These individuals make a commission long after the initial open enrollment period of meeting with individuals for private health insurance.  Yet, their commission should somehow be based on or changed due to member continuation and satisfaction.

The question to the Payer is what role, responsibility, and payment plan you want for the Insurance Agent and/or Broker in today’s environment and moving forward.  Are they to become order takers? If they are paid commissions monthly after the enrollment, do you not think they should be mentoring the member through these rapidly changing times in order to encourage urgent care vs. emergency room?  You may want to encourage health fairs for HSA members to compensate for the lost cost with high quality annual physicals so less money is taken out of their pockets and more is kept in their HSA account.

Are we looking at a clinician and non-clinician relationship as seen today in care management; that is non-agent (order taker) and agent?  Would the latter be in-house or all contractors? Would the broker be a service or partner in an ACO?

What will the Insurance Agent/Broker role be in an ACO?  We still need that first human contact for sign-up and support for all the questions after the enrollment.

Should Insurance Agents/Brokers become contractors to Payer or to an ACO?  Remember they are licensed within the state which should be leveraged.

If you are a CEO, does your BPM include Marketing/Sales and the role/responsibility of Insurance Agent/Broker?  How will this be addressed with the ACO?  What can be done today to leverage, incentivize, and track performance not on enrollments?

I will plan to blog more about this since I have been an insurance agent for employers and private citizens and provided the following suite of products:  Multiple Healthcare Payer Plans, Colonial Life Supplemental Products, Life Coverage, etc.  I know the ins and outs of pharmacy too.

In addition, I have worked as project/product manager for a payer/carrier in Marketing/Sales and delivered on HSA, HRA, Old to New PBM and Enhancements to HMO, PPO, POS, etc.

My assumption is that we have not gone far enough upstream with this process and role for Member-centric Care, especially with an ACO.  We have worked on Payer and Association of Providers (networking) contracts and structure.

Most of my readings and exposure has seen a focus on the middle of a collaboration and rather ignore the Agent/Broker, which I think is a missed opportunity for member persistency and satisfaction for successful Member-Centric Care.

I am looking forward for your thoughts on business transformation with sales and Insurance Agents/Brokers.

Receiving Outcome Incentive Payments Requires more than “Outcomes” from Providers

Paying healthcare providers to meet defined quality goals has experienced an uptick in acceptance and appeal lately.  Given the fact that the quality of care in the United States has been unresponsive to decades worth of public reporting and benchmarking efforts, one can’t help but to wonder if a financial incentive to providers and physicians will be of much use. 

Within the past few months, heavy hitters such as UnitedHealth Group and WellPoint announced that they will change the way they pay providers and hospitals.  The goal of this effort is to overcome fee-for-service short-comings by making patient outcomes a part of payment structures. 

This is a concept that has long been hailed as a solution to overcome the rapidly inflating healthcare costs and unresponsive outcomes.  The 2001 Institute of Medicine (IOM) report titled, Crossing the Quality Chasm, discussed how U.S. healthcare quality failed to establish benchmarks to measure care based on the best available practice.  It stated that the problem with outcomes within the healthcare industry is based in the fact that provider practice patterns differand those differences in practice patterns are responsible for staggering differences in cost of care and outcomes.  Ultimately, the report suggests that providers who want to address outcome discrepancies should start by adhering to evidence-based practice patterns.

Provider Needs
This introduces two needs for providers:  Knowledge of Best Practice Patterns (Order Sets) and Business Intelligence. Providers who adhere to evidence-based order sets are expected to have increases in treatment outcomes.  However, before any provider changes their practice patterns there must be evidence that the change works.  For example, the Grey Bruce order set project   found that physicians using order sets were 143% more likely to order a specific life saving drug for heart attack patients if they used an order set.  If the proper evidence is supplied then the first hurdle is negated.

The second hurdle to improving outcomes and adhering to order sets is accessibility to a robust evidence-based clinical decision support system to improve outcomes and lower costs per case.  Part of this system should be a repository to keep physicians abreast of the relevant publications regarding order sets and other evidence based practice insight.  The second part of the system should track and report out on physician order sets within their facility.  By having access to the appropriate scholarly publications and facility physician practice patterns, physicians may find that certain “tweeks” to an order set improve outcomes at their facility or within a certain group of patients while other “tweeks” may hinder outcomes. 

Most of the necessary data is captured by systems within an organization, but many organizations are struggling to find a way to access and use the data.  Whether the goal is to meet the financial incentives offered by providers or to lower costs of care, it is impossible to address practice patterns and outcome issues without a business intelligence solution that provides insight into the business and/or physician.  Organizations investing in such systems will not only have a leg up on competitors, but they will also be more likely to meet the incentive payment requirements – and ultimately have healthier patients and receive more money from payors. 

The future of healthcare looks much different than yesterday.  For organizations and physicians who are nimble and stay in front of the curve, survival will be fairly painless.  The rest – they will learn to evolve.

Looking Forward: Measuring Healthcare Quality

Compared to other nations, the United States has difficulty measuring up to some key areas related to health care quality. In terms of life expectancy, Docteur and Berenson (2009) contend that the United States has one of the lowest life expectancy rates and the highest mortality rate from conditions that could have been prevented. These disturbing statistics may be explained by the examining how the World Health Organization’s (WHO) and the Institute of Medicine’s (IOM) “key components to achieving a high-quality healthcare system” fit into care rendered within the US.

According to the WHO and the IOM there are key components to delivering high-quality care, such as:
1. Safety,
2. Effectiveness,
3. Patient-centered,
4. Timeliness,
5. Efficient, and
6. Equitability.

If we accept that the WHO and IMO are correct, then we must ask did the HIT Act assist in improving healthcare quality? To answer this question we need two things: analytical tools and continuous patient data. Analytical tools are needed to focus on each key component deemed necessary to deliver high-quality care separately and then synthesize outcomes to provide a comprehensive illustration of actual patient outcomes. To illustrate patient outcomes, patient information must be shared amongst providers – hence EMRs and HIEs are a necessary element for all providers.

By integrating analytics with EMRs (and soon ICD-10), care rendered can be analyzed for quality from an outcome perspective. Each of the key components could be evaluated as criterion on a Provider Quality Scorecard and published and reported back to the appropriate healthcare agency.  By doing this providers are given information about the care they are providing, organizations can evaluate what constraints within their system are affecting quality and govenment agencies can evaluate overall weaknesses and strengths within the healthcare system.

Provider Quality Scorecard





# of injured patients
# of staff injuries


Post-op care instructions
Pre-op options education


Follow up w PCP
Follow up visit


Discharges to LT care


Test Results
Staff timeliness




Is quality the future of healthcare in the US? Only time will tell how we will use our tools to cure the ailing healthcare system.  However, the most important part is using them to provide much needed knowledge to providers and begin to the march patients, providers and healthcare organizations down their road to recovery.


HIEs post another Win within the Healthcare Industry

One of the most costly and concerning healthcare expenditures is emergency room visits.  Providers and payers are especially concerned with the uptick in ER visits, because ER visits are known to be extra costly and peppered with discressionary visits.  Providers and payers have decided lowering ER useage could be done by identifying ER abusers and preventing people from getting sick.  However, to do this having access to information is necessary.   In a recent report in Healthcare Payer News UnitedHealthcare discussed how they have reduced hospital and ER usage, increased quality and decreased operating costs by sharing patient data through a healthcare information exchange (HIE).

HIEs are known to improve coordinated care and care management as well as minimize unnecessary costs by sharing patient information amongst payers and providers.  UnitedHealthcare cited an additional HIE advantage from its real-time system – better follow up care which resulted in lower readmission rates and fewer ER visits.  Dr. Sam Ho, the executive Vice President and Chief Medical Officer at UnitedHealthcare, noted that HIEs will be critical for ER and Inpatient services because, “that is where the most discretionary utilization occurs, and that’s where the most impact can be achieved in terms of developing more affordable services and healthcare.”

In a previous post a colleague of mine identified 9 key drivers to enterprise HIE .  Of these drivers there are 3 that benefit everyone involved:

Ensuring appropriate care is given at the correct time:  Enterprise HIEs are driven by the clinical goal of ensuring that the appropriate level of care is provided to patients in a timely manner.

Promoting preventive medicine: Preventive medical services traditionally occur within a conglomerate of divergent clinical care settings.  An appropriate Enterprise HIE solution must drive disease-management programs to promote preventive medicine services and reduce the costs associated with these critical health care services overall.

A self-sustaining business model:  An Enterprise HIE must be born from a strong business model that is self-sustaining and not overtly dependent on grant funding alone in order to be successful.  With the advent of healthcare reform, this strong business model will provide an efficient foundation upon which many more citizens can be incorporated into the existing ecosystem as will be required.

Together these three objectives explain how the industry will do more with less.  HIEs are electronic powerhouses that move and connect information from disparate systems to different parties to promote quality through connected and informed care.  In return organizations are better able to decrease excessive and unnecessary costs such as unnecessary ER visits and other healthcare misuses through analyses on data sets which identify operational weaknesses and high-risk patients within the system.  Success stories, like that of UnitedHealthcare, reiterate the importance of HIEs within the industry.

How the Healthcare CIO Saves Lives

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.

Healthcare and Business Process Management Interview [VIDEO] at IBM Impact

Trouble viewing? Check out the link to the video here

Joel Thimsen, Solution Director at Perficient, was interviewed by Scott Laningham, Host of developerWorks, and Todd “Turbo” Watson, Blogger/Technology Evangelist, at IBM Impact in Las Vegas.  Joel outlined Perficient’s 12 year partnership with IBM and some of the key trends he has seen when working with Perficient clients.

Joel provided insight into Business Process Management (BPM), which is the practice of optimizing processes with technology for increased agilty and ROI.   He stated that customer sentiment around BPM is positive, and he finds it helpful to guide clients through the process of how to best utilize technology to transform their business.

Joel further outlined the importance of technologies like BPM in the Healthcare industry, noting that there is a lot of activity in the healthcare space.  This rich ground for optimization is largely driven by regulatory changes and an overall drive to reduce healthcare costs.  He noted the importance of finding the right balance point between shrinking IT investment and innovation that provides more alignment between the healthcare business and IT.  He stated that BPM technologies can be tailored to each organization, and their underlying project needs, to provide quality solutions at the right price. 

“Don’t bring in with a dump truck what could be brought in with a shovel,”  noted Joel.

In closing, Joel mention that virtualization and cloud technologies, both private and public, are hot topics in terms of both technology and a business/cost savings stand point.