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 employer 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.

More than 15 years ago, in response to an increase in the abuse of personal health information (PHI), HIPAA was established to protect the privacy of you as a patient and to prevent improper disclosure and use of that information. HIPAA specifically applies to covered entities, or CEs. Initially, CEs were defined as payers or health plans, providers and clearinghouses. There is a fourth group that was indirectly identified, known as business associates (BAs), who are third parties contracted by a CE to perform duties and services where there’s a possibility that they might come into contact with PHI. In support of a BA relationship, a Business Associate Agreement or BAA must be part of the contractual arrangement.

As it pertains to PHI, there were two rules introduced. The first is the Privacy Rule. This rule requires that CEs use appropriate safeguards to protect a patient’s medical record and other PHI, sets limits and conditions on uses and disclosures with patient authorization, and provides patients the right to access and examine their PHI. The second rule is the Security Rule. This rule requires CEs (and BAs) to follow established national standards to protect electronic PHI, or ePHI. There are 3 categories of safeguards that must be observed: administrative, physical and technical. HIPAA and the accompanying Privacy and Security Rules are law, and must be complied with. Non-compliance can result in a fine, potential civil lawsuits and getting your organization’s name on the CMS “Wall of Shame.” An example of non-compliance is a breach or situation where ePHI has been “lost.” The CMS fine for each breach can be as high as $1.5M.

Now, focusing on Business Associates, there was a change earlier in 2013 that now makes a BA directly liable for non-compliance with HIPAA. As such, if not done already, each BA must review the law, understand what privacy means to the services and products provided under contract with a CE and take action to comply with the security standards and safeguards. The Security Rule begins with an assessment, which must be done on an annual basis, to determine which of the 42 security safeguards apply to the BA. The standard BAA essentially requires the BA to comply with HIPAA. One of the 20 required safeguards is education and awareness of the Privacy and Security Rules. As such, each employee of the BA that is involved in an engagement involving PHI/ePHI must go through an online program to help them understand the Privacy and Security Rules and what their responsibility is. It’s not uncommon that a CE may impose additional contractual obligations on the BA that go beyond the standard BAA.

The Centers for Medicare & Medicaid Services (CMS), has stepped up the enforcement of HIPAA. Earlier this year they completed the first annual audit of CEs. Now that BAs are directly liable, the next annual CMS audit will include randomly selected (small, medium, large) BAs. Particularly for BAs, a lack of compliance can be business impacting as the results of the audit are made available.

Even though CEs have been required to comply with the Privacy Rule for the last 10 years and the Security Rule the last 8 years, many are not. In the first CMS audit done, 59 of the 61 providers were not compliant. Shockingly, 35% of the time the reason for not being compliant was ignorance. I’m not sure what’s worse, being ignorant 1/3 of the time or knowingly non-compliant 2/3 of the time. With the greatly increased funding for enforcement, it won’t matter as public knowledge of BAs non-compliance will cost more than any fine CMS could level will.

Now’s the time to get compliant! In particular for BAs, given the recent changes to the law, take heed as you’re probably not compliant. Being compliant with HIPAA is not only required by law, but doing so gets your organization down the path towards best demonstrated practices with respect to security in general. Believe it or not, the HIPAA Security Rule isn’t all encompassing. If you’re not sure about the next steps, then engage some outside help. The sooner you get started, the better.

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. Make 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.

Serving Suggestions:

Instead of deciding which plates, spoons and forks to use for consuming the gumbo, this is the exciting process of selecting which tools to use for the consumption. The ones to use will be based upon the number and type of guests, prevailing technology standards and the current capability to serve up the required information as input. Business operations typically prefer basic reporting and analytics, whereas informatics will have a more complex taste, looking for statistical analysis and data mining. Everyone’s preference can be met; the more complex pieces just may take longer given the information need, the organization’s maturity and capability around consuming the information and, most importantly, ability to act upon the results.

Thoughts:

I know this is a little tongue in cheek, no pun intended, but meant to illustrate a view on how to approach an EIM. At first, particularly if you have tried in the past to roll out an EIM or part of one and didn’t succeed, the effort can seem daunting. To be successful, you need to have a plan your recipe, take the time to understand and envision what it will look like at the various stages, be deliberate in your actions and get buy-in through involvement and ownership. An underlying implication in the recipe and the last statement deals with two important aspects of the effort. You need to take the effort a step at a time. This enables you to involve who you need on a scale that doesn’t mean the whole organization. The who refers to a team of technology and business folks, integrated and working together. This type of effort cannot be done if it’s only one function in the organization carrying the proverbial cross.

Lastly, there may be the temptation to cut corners and buy something canned. I admit, that path can look attractive, particularly if there have been past challenges. Don’t fall prey to that, though. For the EIM to become part of the organizations culture of execution and service excellence, you need to cook the EIM dish from scratch. Part of moving up the EIM maturity cycle is going through the iterative process of learning from mistakes, benefiting from the successes and delivering value at an incremental pace, even if the initial deliveries are basic. Remember, it’s your business, your people know it; they know the data, information, products, services, customer and each other the best.

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!

To illustrate the opportunity to move to an active model, here are 5 use cases that could be enabled:

1. Risk categorization – Critical to engagement with your members is an on-going process that continuously reviews and determines each member’s level of risk. I’m partial to the John Hopkins ACG or Adjusted Clinical Groups system. It’s a good industry standard, actively maintained and used, performs well at the individual level, and does a good job at categorize both healthy members as well as those with chronic illness and/or events underway.
2. Provider referral – This is a common need. Instead of assuming the member will search for a provider at the appropriate time or in response to a particular event, do it actively. Upon on a combination of factors including the following of an appropriate preventive regimen send a suggestion or alert to the member listing providers within a reasonable radius in the appropriate specialty. Suggestion can be based upon age or chronic disease occurrence, current healthcare utilization identified by claims, prescriptions and pre-authorizations or just wellness programs. An example could be a healthy, 50 year old with no claims history. Send a list of primary care/family physicians to them with the suggestion that they get a checkup and discuss the need for a prostate exam and colonoscopy.
3. Target content delivery – Today, when any member logs in, they typically see a standard or common view. If there is configuration, it is typically around the type of insurance product or services purchased. Further leveraging engagement programs based upon the risk categorization and demographics of the member, dynamically deliver content that is appropriate and targeted to them. A challenge here would be recognizing the various permutations, but start with the most common and work from there. Worst case, today’s current view would be a default. At the very least, when a member logs in to the service portal for the first time, a quick questionnaire (basic health risk assessment!) could be done to set a baseline for engaging with them.
4. Disease oriented preventive treatment programs (Focus on the big 5 – heart disease, cancer, stroke, chronic obstructive pulmonary disease [bronchitis, emphysema] and diabetes) – If the member has one or more of the major/common chronic diseases, such as diabetes, there is a well document regime of care that they should be following. Developing little “apps” or pockets of OBI and BPM/workflows around helping a member take care of themself can be delivered. You will have the risk categorization; claims show instances of care and prescriptions showing drug and consumable use. An app deployed on a smart device, delivered in a way to encourage participation (using gamification or other engagement tactics), that facilitates the member taking care of themselves, adjusting the suggested regimen based upon events underway, can help the member to maintain a reasonable quality of life in spite of the situation, be kept informed, educated and aware and provide a history potentially available to their caregivers. Employing gamification techniques specifically makes a game out of managing the available of test strips, routine glucose testing, or delivery of insulin. The achievement of certain targets could be accompanied by an award. Even something as simple as receiving a gold star for a certain performance. It’s even something that they could potentially tweet or Facebook about to family and friends.
5. Annual enrollment planning – This can involve the predictive modeling aspect of risk categorization and past consumption of care. In the situation where there are multiple offerings that would be available to a member, providing them the ability to understand their past and future consumption can allow them to make the best financial decision for themselves. Today, the individual is left to try and figure this out on their own. When a member is part of a group offering, the selection list may not be very long at all, so there isn’t much choice, but with the risk in consumerism as a result of the new HIXs, this will be important. While the individual will go back to the HIX to elect or renew, there’s no reason why you can’t help them by ensuring that they are an educated consumer. Your goodwill and openness will drive retention.

There will be several challenges to implementing an active approach for member engagement. First, risk categorization: is your organization doing this, where’s it being done, and is the information accessible and usable at a member level? Second, you will need to incorporate a Workflow/BPM element and work with your clinical folks to encapsulate particular engagement programs (for example, chronic, preventive, wellness) into a workflow and define the conditions that would drive the use of each. Next, your portal and everything “within” it needs to be easily accessible on members’ mobile/smart devices. How about content management? What are your current capabilities with respect to this? Is it basic file storage and delivery or something more complex? And, bringing everything together, a portal solution incorporating analytics, workflow and content management is needed and a great starting point.

The pot of gold at the end of the rainbow is there. To get it will take hard work, an investment in time and people, along with a willingness to organizationally embrace change and a new perspective at engagement with members. With the move down the consumer path that Healthcare Reform is driving, the new individual consumer will expect, appreciate and respond to such an active, dynamic approach delivered in a “socially” conscious, mobile manner.

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 1^st 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 subsequent 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.

The second, potentially greater and more impacting, opportunity is to revisit the existing solution used to service members. As I alluded to above, you still need to continue to execute on the current service norms, but those norms need to be added to and enhanced for this new world. Given the traditional sales dynamics mentioned earlier, the current “member” services platform and process tends to lean more toward a ticking of the proverbial box in order to sell to and win the block of business from the decision maker/broker/agent combos. In terms of basic expected features, as long as someone can look up a provider, check on a claim, maybe refill their mail-order prescription, it was ok. That won’t work with the individual buyer. To ensure your retention level is high/churn is low, you are going to need to enhance your member services, maintaining continuity with the new consumer engagement branding, engagement and activities. This change event also provides another opportunity to up your game. In the spirit of this broader consumer engagement, these member services can be enhanced. It’s time to move from passive, like an email that says “hey, you have a claim,” to something much more dynamic. Through risk stratification, the use of business intelligence, consumer personalization, the notion of consumer engagement begin with the initial sale, carries on through to the service “side.” For example, if a member made a recent visit to their primary care or family physician, as evidenced by a claim, you can actively review the claim for diagnosis and treatment, say note the need for a specialist and reach out to them with a suggestion for specialists that live in the area. Or, when the member “signs in,” dynamically display content and interaction based upon their profile and utilization. You have the opportunity to actively engage with the member creating a better experience for them, not to mention a healthier one and by leveraging technology and information, provided for a lower cost to serve.

So, the Healthcare Insurance Marketplace is coming! Are you ready to make the most of it?

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, 3^rd 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.

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.

For an example of a broader, potential long-term impact of HCR is what the currently insured people pay. For example, with subsidized coverage through HIXs and Medicaid expansion, we’ve been told that healthcare spend will go up as the uninsured will now have access to insurance which will have to be paid. Well, it will, if the providers don’t adjust their pricing. What does adjust pricing mean? If you look at the cost side for providers today, all of the costs they incur to “service” the current uninsured, including salaries, supplies, insurance, facilities, etc. are built into the pricing that those with insurance are charged. If the past uninsured now have coverage, with their bills now being paid, and the providers don’t adjust down their pricing, anything the providers now receive for what used to not be paid will drop directly to the bottom-line, pure profit. Ideally, the current spend will not change, it will be redistributed.

I promised to explain my comment “with some help.” This refers to other, maybe coincidental, changes with society and the population as a whole. Prospective patients are better educated about the appropriate use of healthcare. After a decade or more of being inundated with information, people are getting smarter about how to take care of themselves, eating better, exercising, preventive care and so on. Consumer technology is playing a role here as well. Being informed means just that, better access to information on one’s self, how to measure your health against baselines or benchmarks. The huge growth of smartphones has taken information consumption to a new level. Individuals desire to have easy access to everything about themselves, tweeting and Facebooking it to family and friends, creating a heightened level of engagement. Social media and concepts such as gamification are having their impact. Whether it’s an app that tracks your route and distance, sharing it every time you walk or run, or a health wellness app that has you tracking your personal health score, much like you track your credit score, telling you what you can do to increase it. This level of consumer driven engagement or “pull” will continue to have a positive impact on people health and healthcare spending.

The “production” side, better known as Providers, is now experiencing what many in other industries did in the 90s and last decade. They’ve rolled out or are close to completing the roll out of transactional systems to support an Electronic Medical Record (EMR). With this transition from paper to electronic records (EHRs), there is now a big desire to do something with all of that structured data. Over the last year or so, the requests for assisting with Analytics and Business Intelligence (BI) efforts have grown dramatically. A good example of this trend could be seen at the HIMSS conference that just concluded. Everywhere you looked, someone had a BI offering. That’s all well and good, but there’s no short-cut to getting good BI and it requires an investment on par with what was spent deploying the EMR systems. The first steps need to be focused on Data Governance, Data Management, defining your organizational goals and strategies and the value expected to be derived. It doesn’t pay to rush in and begin grabbing and trying to use what seems like readily available data. The best approach is to tackle this huge demand by incrementally building out the organization, processes and procedures required. This ensures that the subsequent consumption is appropriate, value-adding, needed and timely. When was the last time the “big bang” approach really worked or took hold within an organization?

With any effort of great size and complexity, there can be misunderstandings and misinterpretations at the beginning. It doesn’t get any bigger than Healthcare Reform. There are a couple of analogies that come to mind, like you can’t eat an elephant in one bite, nor can you turn a super tanker on a dime. Healthcare reform is more like a herd of elephants or fleet of tankers. But have faith, it is beginning to work, and we should be looking for positive refinements as it is dependent on 300 million people continuing to take better care of themselves…

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.

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.

How to tackle this challenge? A place to start is needed. So how do you identify one? There are processes and tools in the marketplace that enable the leveraging of bills/claims for analysis looking through and ICD-9 to ICD-10 “viewer.” An organization can be enabled to use this approach to develop/refine their ICD-9/ICD-10 cross-reference, understand and examine the most frequent activities and areas of greatest revenue impact, establish priorities for Clinical Document and other standards initiatives, develop, schedule and deliver communication, training and education to the organization and drive the remediation of the supporting technology platforms and systems.

The first step is developing your organizations ICD-10 Cross-Walk. Remember, the published GEMs are fairly ambiguous “off-the-shelf” and need clarification with respect to your organization’s norms. The use of GEMs shouldn’t include on-going operations unless a partner is late in compliance and you have no choice. Even with a well-vetted cross-reference, much is still lost. Many organizations are dependent on a mix of EHR, Billing and BI solutions, each needing to use the Cross-Walk in its own way. A good solution facilitates the distribution to the point of consumption and, as needed, can provide an audit trail when use of the Cross-Walk is required in one of those urgent situations.

Long term, there will be an ability to derive benefit from the efforts required to comply with ICD-10. I would suggest that the refocus and refinement via Clinical Document Initiatives will drive better quality billings out the door, reduce your receivables with quicker reimbursements, reduce rework, particularly the amount of time lost when billing has to go back to the clinical folks for clarification, and, lastly, the diagnosis code will now be infinitely more useful for analysis and measurement, with an eye toward outcomes and the long-term well-being of the population.

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 3^rd 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(R) (ACG(R)) 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.

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.

So, we have Reporting and Analytics. What is BI? Business Intelligence (BI) is complex, broad, and requires a great deal of foundational work and organizational commitment for it to be successful. It’s not just an IT thing. Simply put, you start by collecting the organization’s data, giving it meaning through employment of data governance and management practices, which leads to the creation of information, a corporate asset. Next, it’s about understanding the organization’s norms, so that they can be easily described and rules defined to represent them. Lastly, there’s innovation and opportunity. BI enables innovation by allowing you to venture outside of the box or norm and discover new opportunities that are within the organizations current capabilities to deliver. These epiphanies provide opportunities for your organization to grow and add value through continued improvement and expansion of its products and services.

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.

Phased Client/Product “Conversion”

It’s very difficult to migrate every client and product offering all at once. Ideally, the incoming claim volumes would be segmented in a way that provides for a challenging, yet achievable monthly migration schedule, typically focusing on blocks of business. These blocks could be product or customer related. Start small and ramp up as the first month or two will allow for refinement of the process such that succeeding months will go more smoothly. The timing allows for vetting the extracted source data into the repository, applying all transformation rules and logic, and then reviewing/dealing with kickouts, group building, plan building, billing, training and appropriate communication. It is suggested that you allow for up to two weeks for the first couple of months, moving to one week going forward. Operations will be required to pay down all open claims for each block of business targeted to move that month, eliminating any backlog. The week provides time to perform all the activities related to migrating that block of business and allowing for resolution of any issues. While each block is migrated, during the week of downtime, a portion of the existing Operations folks would undertake orientation, training and made ready for life with the new platform. Particularly early on, there will need to be some staff augmentation in Operations to support the migration.

Reference Data

If not already in place, it is recommended that the management of Provider and Eligibility information be done on a platform separate from the claims processing system. These two sets of data are key to the processing of claims and their accuracy, which is critical to turn-around, throughput and quality. By managing this information off-line, you can institute appropriate controls and quality review procedures. On a regular basis, updates would be released to any target claims platform. During a claims migration or consolidation of an acquisition, being able to handle and manage these two sets offline allows for a smoother transition, as management is done centrally and updates can be pushed out to the old and new claim platform concurrently.

Cohesive, Company-wide Effort

The Migration plan should take into account and provide for all activities related to the effort, including, but not limited to Technology, Operations, Account Management, Compliance, Provider Management and vendor relationships. The technology is the easy part, operationalization, execution and management of the change from an overall business perspective will be difficult. To ensure the short and long term success of the effort, look at backfilling key individuals from the various parts of the organization and putting them on the project team full-time.

Long-term benefits to the organization

Acquisition Consolidation

The block-by-block of business approach provides for the creation of a template or repeatable process. Doing so not only helps to ensure the success of the current migration, but provides the foundation for and capability to more easily consolidate acquisitions. The tools, mechanisms, procedures, rules and information model created can be re-used. Most importantly, the folks that were assigned to the original migration effort are now back in their respective areas and are familiar with template.

Data Warehousing

Leverage the work done in building the repository to help drive the establishment of an Enterprise Data Warehouse. The movement of data into and out of the new Target platform is reusable in an on-going basis for the ETL’ing of data for Business Intelligence. As new Standard Operating Procedures, User Reference Manuals and other processes are being defined, develop the new workflows in a way that allow for easier monitoring through the movement of operational data to the new EDW for Throughput, Backlog, Exception and Productivity reporting. Further analytics around topic areas such as Population Health, product design and quality can be supported.

Data Repository/Data Integration Service (SOA)

The repository can become a foundational component for data integration services that enable the organization to easily source and exchange data across the various application platforms and use cases internally, as well as with external partners. The repository can provide for a level of abstraction, allowing each platform to be connected once, then accessible to all as required by the business.

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!”