Unprecedented disruptions are driving the industry toward more agile technologies and business practices in order to maintain a competitive advantage.
As noted in part one (“2012: The year to 'Build for Change'”) of this three-part series, the U.S. healthcare industry has weathered major disruption over the past two years. Across various sectors of healthcare, we've all worked feverishly to address the numerous mandates associated with ARRA, ACA, HIPAA 5010 and ICD-10. While these efforts are well under way, and in some aspects are already fruitful, there is still much more work to be done as the uneasiness looms for several years.
In part one, we focused on health plans and how the next-generation healthcare — being brought about by rapid, major mandates and market changes — requires that they move beyond their traditional role of “payer” and simultaneously become both a trusted advisor and health coach. This requires health plans to deploy technologies such as business process management (BPM), decision management and dynamic case management.
Now, we'll focus on healthcare providers, and how they are affected by the next-generation healthcare.
For healthcare providers, the emerging healthcare model forces a move to managing the health of each individual in a population. Major efforts have focused recently on achieving meaningful use (MU) of the EHR. Lost in the MU rhetoric around requirements for data capture of patient encounter is this simple fact: Quality outcomes for each patient/member over the long term should result from intelligent, thorough use of an electronic health record that is complete and up to date. It is not about data capture, but rather about using the EHR for clinical efficacy. Additionally, there have been intense efforts around the formal accountable care organization (ACO) model, as well as other risk-based derivations being implemented.
Both MU and ACO mandates force a major shift to the wellness model — that is, keeping people well rather than treating sick patients. These, along with other mandates and market forces like consumerism, shift healthcare providers away from the traditional encounter-based, sickness model. The shift diminishes the dominant fee-for-service payment model and incentivizes providers to focus on the long term, quality outcomes and lower costs for members. As a result, it is now critical for providers to refocus on patients/members as customers, to effectively deliver wellness programs, efficiently coordinate patient care across various settings and to tailor services to each individual.
Typical core technologies for providers — including HIS, EHR and practice management systems — are designed to manage patient encounters, but they are inadequate for managing patients/members as customers. Workflow for these systems is tied to the old paradigm of transactions and encounter-based treatment. To augment and leverage core technologies, healthcare providers must deploy BPM, customer relationship management (CRM) and dynamic case management to be both more efficient and more personalized in all their patient/member interactions.
Currently, healthcare providers rarely have CRM systems in place. Yet, these are the backbone of virtually all service industries around the world, while providers of healthcare services instead rely on basic telephonic equipment and disparate transaction systems to support disconnected departments with throngs of staff. Customer-facing departments such as registration, scheduling, admissions, care management and patient financial services are almost universally regarded as inefficient and costly, yet this is where the customer experience starts and ends. With next-generation healthcare, these departments are interacting with ever larger populations — members rather than just patients — and the inefficiencies and poor service are being exposed, thus magnifying many resulting problems. Providers must embrace intelligent CRM to deliver quality customer experiences by providing a single, comprehensive view of patients/members with information that cuts across disparate clinical, operational and financial systems and corporate silos.
Intelligent CRM is powered by BPM. Rules and workflow processes within industry-leading BPM technology deliver a comprehensive customer view, no matter how many various systems there are. This guides staff through streamlined processes while providing timely, pertinent information throughout the interaction, creating a wholly satisfying experience to patients/members.
Dynamic case management, not to be confused with the more narrow healthcare definition of clinical services for a patient during a clinical encounter, is the orchestration of complex work encompassing numerous work deliverables and participants, each with their own processes and deadlines. For healthcare providers, this is the orchestration of everything — directly and indirectly — associated with patients/members. Dynamic case management intelligently coordinates the workflow of clinical, operational and financial staff, processes and systems — eliminating the effect of silos that so typically separate these functional areas and frustrate patients/members.
In combination, BPM, CRM and dynamic case management empower healthcare providers with more flexibility, agility and intelligence necessary to take a customer-centric approach to emerging industry changes. Several innovative, forward-thinking peers are already using these technologies to leverage and extend existing systems and have created a technology platform with better capabilities to address future changes.
About the authors
Elizabeth Hart and Bill Marshall are both principals in Healthcare Industry Solutions at Pegasystems. Pega's Build for Change technology is driving transformation at three of the largest pharmacy benefit managers (PBMs), 13 out of the 15 largest health payers and more than 65% of the Blues network. PBM clients handle more than 55% of the nation's prescription volume; payer clients write more than 50% of all direct premiums. Learn more about Pegasystems solutions at www.pega.com.
