Managing Managed Care Integrations – What’s the Problem?

Remember the old children’s game called “Telephone?” Where you whisper something into the ear of one of your friends, and they turn around and whisper it into the next child’s ear, and so on down the line until the last person recites the secret message and everyone laughs because the final message bears so little resemblance to the starting message?

Well, that might be fun out on the playground, but it’s no laughing matter when it comes to healthcare. As a patient, if you’ve ever been in for multiple visits with different specialists for a health-related problem, you may have wondered if something similar wasn’t happening in the communications process when different laboratories, clinics, and healthcare workers tried to exchange information about your ailments, conditions, or treatments. It makes you begin to think about what application and data integration can do in the healthcare world — especially from a patient’s perspective.

What if all your doctors, nurses, and specialists could operate off a single medical record that consolidates your broad range of medical history and multiple clinical tests? Even managed care organizations such as HMOs that have built a network of physicians, hospitals, and health care centers often find they aren’t able to easily integrate and share information across these resources.

In the 1980s, banks consolidated their financial information and customer management systems around customers, not accounts, in order to capture a greater share of the market and hold onto more customers as the industry evolved. In the 1990s, integrating applications, data, and the supply chain made a lot of sense for manufacturing companies that wanted to reduce cycle times, reduce costs, and streamline their business processes. Today, integrating enterprise information makes a lot of sense for Fortune 500 companies, as well as just about all other sizes of companies.

What about the managed care portion of the healthcare community? Is the time ripe for managed organizations to take advantage of integration technologies and new Internet capabilities in order to provide patients, doctors, and managed care providers a complete and unified view of a person’s medical history?

In fact, while managed care organizations have invested billions of dollars in best-of-breed applications designed to help contain costs and increase the quality of care delivered to their members, they’re also finding that automation by itself is critical, but insufficient. They must broaden their focus to look at today’s available technology to integrate their separate systems and automate the processes supporting the entire continuum of care. By leveraging their investments in automation to create an integrated platform and extending it to their providers, managed care organizations have the opportunity to lead the healthcare industry to new levels of collaboration.

Even though managed care organizations have a clear financial stake in streamlining patient care and reducing costs, they often find it difficult to unify disparate silos of patient information. For instance, a managed care organization may be coping with individual applications ranging from case, disease, utilization, and authorization management, as well as data analytics and reporting and provider analysis. These applications are frequently stand-alone or only loosely joined to each other, so that generating a holistic or complete view of a subscriber and his or her medical needs is impossible or incomplete. In addition, healthcare providers are continually being pushed to integrate more with external data sources, such as eligibility and online claims systems, or incoming data feeds from pharmacies or clinical systems.

If one looks back at the history of integration in the financial services markets in the 80s and 90s, they’ll see that a main driver was the need for the CEO to have a complete view of his business, and enable managers to operate off a single, consolidated set of business measurements, rather than a diverse collection of differing numbers. Integration of the financials and line of business applications resulted in the ability of CEOs and managers to operate off the same page, focus on the same goals, and have a clear understanding of the progress (or lack thereof) that they were making.

Health care providers, with their collections of individual clinical and financial systems, have that same potential, to enable patients and their doctors to have a complete view of a patient’s medical history and proactively diagnose and treat diseases and potential problems. In the next column, we’ll look a little more closely at this subject to explore some of the solutions that are being proposed and used.

About the Author

David Kelly - With twenty years at the cutting edge of enterprise infrastructure, David A. Kelly is ebizQ's Community Manager for Optimizing Business/IT Management. This category includes IT governance, SOA governance,and compliance, risk management, ITIL, business service management,registries and more.

As Community Manager, David will blog and podcast to keep the ebizQ community fully informed on all the important news and breakthroughs relevant to enterprise governance. David will also be responsible for publishing press releases, taking briefings, and overseeing vendor submitted feature articles to run on ebizQ. In addition, each week, David will compile the week's most important news and views in a newsletter emailed out to ebizQ's ever-growing Governance community. David Kelly is ideally suited to be ebizQ's Governing the Infrastructure Community Manager as he has been involved with application development, project management, and product development for over twenty years. As a technology and business analyst, David has been researching, writing and speaking on governance-related topics for over a decade.

David is an expert in Web services, application development, and enterprise infrastructures. As the former Senior VP of Analyst Services at Hurwitz Group, he has extensive experience in translating the implications of new application development, deployment, and management technologies into practical recommendations for enterprise customers. He's written articles for Computerworld, Software Magazine, the New York Times, and other publications, and spoken at conferences such as Comdex, Software Development, and Internet World. With expertise ranging from application development to enterprise management to integration/B2B services to IP networking and VPNs, Kelly can help companies profit from the diversity of a changing technology landscape.

More by David A. Kelly

About ebizQ

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