Within the managed care organization (MCO), systems integration efforts have typically focused on technically integrating front-end and back-end systems. IT departments have spent a lot money building best-of-breed applications and then maintaining the interaction between those stand-alone systems, and technical integration minimizes the costs of application management and administration. Creating a common back-end database and a common user interface simplifies life for the IT department, which no longer has to support the variety of operating systems, databases, fat clients and other disparate systems associated with a heterogeneous computing environment.
The second stage of systems integration evolution, however, promises an even greater level of savings and competitive advantage to the MCOs that pursue it. Beyond technical integration of care management systems lies their functional integration. Such integration creates a common data flow across individual systems such that information generated by one application feeds related applications to promote actionable information and process automation.
Similar to the IT burden relieved by technical integration, functional integration relieves the work-process burden created when highly trained care management nurses manually execute routine, nonclinical tasks.
By automating standard procedures, functional integration lets nurses focus their clinical skills on those patients who will benefit most from their services. For example, rather than task a nurse with looking up employer-specific benefit plans or manually drafting a written communication to a patient or doctor, functionally integrated systems automate this type of work and free that nurse to focus on the medical needs of the patient.
Functional Integration in Action
A functionally integrated care management system combines a number of independent subsystems or components, including:
* analytics and a predictive modeling component to evaluate providers, patients and plans;
* transactioning components to automate authorizations, referrals and communications with providers and patients;
* utilization management, disease management, case management and other components to manage populations across the continuum of care;
* clinical rules and processes components to ensure the best healthcare practices are delivered to the point of care.
Two additional features distinguish the functionally integrated system. First, it has ties to the MCO's claims system to facilitate analysis and automation. Second, it generates a consolidated record for each member. This payer-based health record (PBHR) grows over time as the MCO accrues medical claims, lab results, pharmacy data, health risk assessments, utilization management authorizations, case and disease management data, and other clinically pertinent data, which is used by all of the integrated system components.
In action, a functionally integrated system will automate much of the work that would otherwise be executed manually or perhaps be overlooked. For example, an MCO could use such a system to run analytics on its member population. The system then hands off the analytics results to the care management component for evaluation.
If the data analysis reveals a large disease population such as diabetes within a given provider's patient list, the system can tag each of the diabetic patients and their records. For a patient needing an ophthalmologist appointment, the system will update his or her PBHR with a "gap in care" notice and then score the patient for risk using other data found in the PBHR. For a low-risk patient, the MCO might want specific literature regarding diabetes and eye care sent to the patient via postal mail, and the system automatically generates that request for literature and sends it to the processing system for fulfillment. The system then flags and prioritizes the patient as "low-risk follow-up" in the case manager's workflow queue, so the case manager can later contact the patient and encourage an ophthalmologist appointment.
Meanwhile, the system will update the patient record with the gap in care and make it available to the provider at the point of care. When the patient sees his or her primary care doctor for an unrelated concern, the doctor can pull the PBHR and see the gap in care. Using the system's transactioning feature, the doctor can submit an ophthalmologist referral to the MCO and the system will automatically approve the referral--all while the patient is in the doctor's office.
In contrast to the above system example, a care management system that lacks functional integration demands human intervention at each stage of the process. After running analytics and reporting on the diabetic population, an MCO staff member must manually enter the report into the disease management system. The disease manager, in turn, passes his or her results to the individual care manager charged with patient follow-up. Similarly, primary care doctors have no automatic, systematic tool for proactively managing or monitoring their patients' disease states. If the primary care provider neglects to ask about a patient's last eye exam, the opportunity to make a referral is lost.
Behind the extreme degree of automation lies each MCO's own unique set of clinical rules, processes and procedures. The functionally integrated system, in turn, executes each automated process in accordance with those standardized rules. For example, the MCO defines what constitutes a diabetic, and then given that set of criteria, what the system should do when it finds a diabetic.
Consolidating Patient Information
At the heart of the functionally integrated system lies the system's PBHR. A forerunner to proposed national electronic health records, the PBHR comprises detailed patient data from labs, physicians, pharmacies, care management plans, self-surveys and other sources associated with and paid for by the MCO.
Within the MCO, the PBHR enables the extreme automation described earlier. Outside the MCO, at the point of care, the record can save lives by making pertinent clinical information available to any healthcare provider, regardless of geography, and thereby facilitate faster and more accurate decisions, diagnoses and treatments.
Before such benefits can be realized, however, the systems must address the technical challenges facing the creation of the records. These challenges include eliminating data duplication, reconciling data and diagnostic conflicts, and maintaining and delivering accurate records in real time.
With their multiple data sources, MCOs must identify and reconcile duplicate data. For example, the PBHR must accurately reflect whether a test result found in two different databases represents one or two tests. Similarly, the system must seek out, identify and mediate conflicts.
Diagnoses present similar obstacles. When a patient with five diagnosed conditions has one of those conditions showing up on claims inconsistently, the system must employ a confirmation process to verify the accuracy of the questioned diagnosis.
Critical to the PBHR's value is timely creation. Today, the PBHR is assembled from individual data records drawn from a variety of disparate payer databases. In the near future, the PBHR will include data from provider systems, often geographically distributed. These records will need to be pulled into a unified view, on the fly, within seconds.
Future standardization efforts will not mitigate the distributed data dilemma. The National Health Information Infrastructure does not provide for the creation of a single, monolithic database wherein all patient data is stored, regardless of source. Moreover, systems that rely on a universal patient identifier to pull data together are simply not politically feasible in the United States. Rather, data will remain strewn across multiple provider and payer databases but will still need to be processed as if they were in one unified, integrated application. Obviously, a functionally integrated application that is accustomed to searching for and assembling data is a good place to start to build this new application that will become the backbone of our future healthcare system.
Despite the challenges, MCOs will reap substantial rewards by deploying functionally integrated, PBHR-driven care management systems today. By automating many of the clinician's routine activities, these systems enable skilled nurses to concentrate on those patients who are most at risk and need human intervention.
Ultimately, the systems help MCOs to reduce time to market, improve staff and clinician productivity, increase organization profitability, improve member and provider relations, penetrate new markets and expand market share in established markets while reducing the costs of acquiring and retaining members.
HMT
