Forecast 2010: Payers

For nearly two decades, healthcare-industry leaders have promoted a nationwide health-information network (NHIN) to help enable clinical-information sharing across multiple institutions and regions. In 2010, there will be unprecedented momentum at the state level to connect health information across providers.

First, the early adopters of health-information networks are showing how sharing clinical information helps drive better clinical decisions, reduce treatment errors and provide a better patient experience. In addition, the ARRA includes $564 million in funding for states to establish health-information exchanges (HIEs). Finally, the maturing of industry standards and the inclusion of HIEs as a part of the meaningful-use criteria is driving state-level adoption. This framework will play a crucial role in eventually achieving connectivity across states, regions and even nations.

There are two models that are effective approaches for states looking to deploy a statewide health-information network. One model creates a “network of networks” based on integrated delivery networks, or health systems within a state. The second model focuses on a master network centralized at the state level, such as Vermont Information Technology Leaders (VITL). VITL is an enhanced primary-care model that coordinates care across the community and leverages a standards-based HIE infrastructure to transmit electronic records data to a quality-reporting system that supports a patient-centered medical home.

In addition to framework, technology standards will also be essential to achieving a connected health information network. Without standards, the stimulus efforts to accelerate adoption of connected care could result in hundreds of state and regional networks that are unable to share information. The Healthcare Information Technology Standards Panel (HITSP) has led the industry in standards definition. Certified adherence to HITSP standards will help enable efficient information sharing, widespread interoperability among organizations and systems, and assure that the investments made today will be extensible into the future.

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HIE Time Has Come

By Antonia Wells, president, Merge Healthcare OEM division

For 2010, expect rapid change — for the better — in health-information exchange (HIE) structure and implementation. Because HIEs are not only government incentivized but also a pragmatic necessity for profitable healthcare delivery, they will evolve into more-consistently successful models in 2010.

The HITECH Act provided $564 million in appropriations for setup of statewide HIEs. With or without incentives, the healthcare system needs the benefits inherent in HIEs. Healthcare delivery demands a new level of efficiency, and technology plays the critical role of automation and efficiency in information sharing. Incremental IT investment needs to deliver a relevant and efficient way to transform healthcare data for the benefit of the patient.

Current models of profitable, cost-saving and quality-improving HIEs are relatively rare. Mostly, this comes from attempts at exchanges that strive to rework the entire health IT system, evolve without clear objectives, or focus on too-broad objectives.

The method of implementation, approach to architecture and key elements of design need to match important short-term objectives, including patient access to relevant and accurate care, operational agility for healthcare enterprises, and effective collaboration among stakeholders in the care-delivery cycle.

HIEs will learn to use what they have to deliver existing laboratory reports, key patient-chart information, and cardiology and radiology data to both primary-care physicians and specialists. Building a basic exchange and then expanding upon it as adoption of health IT grows allows investment to be incremental and more closely matched to direct operational benefits. The system can be more-easily managed without dramatic capital expenditure requirements or significant work flow change-management components.

Interoperability components will go well beyond healthcare-specific standards. Proven open-technology architectures, Web services and SOA solution design, the delivery of Web applications, and the ubiquity of Internet access all provide for an effective deployment infrastructure.

HIEs also will take on more quality-assurance, operational-efficiency and marketing roles, which can be a catalyst for dramatic change in the business of healthcare.

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The Meaningful-use Matrix

By Thomas G. Morrison, co-founder, NaviNet

Through 2010, expect to see government healthcare committees and healthcare IT (HIT) vendors come together to encourage and support adoption of HIT in provider settings across the continuum of care by aligning stimulus payments with quality-care improvements. The goals of the government and the legislation will only be achieved, however, if health industry stakeholders can immediately start to pull costs from the healthcare system.

In order to improve healthcare quality and reduce costs, there are four requirements that need to be supported by the national HIT infrastructure: clinical data acquisition to support cost and quality-effectiveness comparisons; automated support for better-coordinated care and implementation of clinical best practices; process automation to support incentives, payment reform, reporting and liability management; and leveraging the trusted relationship between providers and patients to improve patient compliance with best practices in wellness and chronic-disease management.

Driving the adoption of certified, high-quality EMR capabilities is important for the industry; making clinical data widely available will help reduce medical errors. Less attention is being paid to supporting the behavior and business-process changes that will be necessary to drive cost reductions and quality improvements. Without a broadly accepted consensus, EMR systems will be unable to support the range of innovative new approaches that will be experimented with in coming years. Technology solutions that facilitate business-process innovation in behavioral change for patients and providers are needed to enable cost reduction.

The implementation of new Web-based technologies can help drive the behavior changes needed to accomplish the nation's wellness and prevention goals. The use of Web-based solutions can facilitate many of the quality metrics and corresponding outcomes-based payments.

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Care Management Spotlighted

By Rob Gillette, CEO, Click4Care

In the year ahead, more payers will recognize the strategic importance of re-evaluating their care-management operations and updating them with technology that requires fewer manual processes, seamless integration and more automation. One big driver for the adoption of advanced care-management applications is that payers are recognizing the value in establishing health and wellness programs. This focus on preventive care and early intervention should not change in 2010 — and it may even intensify.

Because current technology relies too much on manual processes and a multitude of segregated silos, payers are challenged in organizing, aggregating and managing member information. They are realizing, however, that investing in newer, innovative technology that presents care managers with the whole picture gives them the ability to proactively reach out to more members with more-targeted wellness approaches.

Case-, disease- and utilization-management programs that help to reduce costly adverse events of high-risk members have been at the core of care management. Payers rely on these programs to provide ongoing communication with members so as to avoid preventable medical complications and hospitalizations. In order to provide the right intervention at the right time, however, the right technology needs to be in place.

In 2010, payers will focus on relieving the manual burdens that stifle work flow and increase the administrative workload of nurse care managers. To allow its nurse care managers to focus on important member communication, payers will look to care-management technology that provides a single, patient-centric view, automates care managers' work flows, has the ability to readily identify gaps in care, and has predictive-modeling capabilities to easily identify members who are likely to develop chronic conditions or diseases.

These care-management solutions need to have the configurability, interoperability and agility to adapt to any scenario that is thrown at payers. Technology that relies heavily on internal IT resources to customize and update work-flow patterns will fall by the wayside. Scalable technology that can be updated by business units will flourish.

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ICD-10 Conversion Looms

by Ray Desrochers, COO, HealthEdge

With the looming ICD-10 conversion, the emergence of value-based benefit programs, and the demand for transparency and accountability, health insurers are facing a perfect storm of demands on their already-stressed technology platforms. In 2010, insurers will begin grappling with the limitations imposed by their hard-coded, legacy claim-processing and benefit-management systems.

Insurers' traditional approach for handling situations beyond the capabilities of their technology will not be a workable option. In short, yesteryear's technology platforms do not have the ability to handle real-time configurability, nor the sophistication that will be required to survive what the future will likely hold.

Health-insurance com-panies cannot afford to slow their efforts to prepare for the change to ICD-10. In some ways, their need is even more urgent, since many providers may start submitting claims using ICD-10 before the 2013 deadline. Insurers will likely be required to process claims using both coding systems simultaneously until the final cutover is complete. Simply installing a separate ICD-10 system is not the answer, since this approach will exponentially increase the cost and complexity associated with maintaining the insurer's healthcare-system infrastructure.

The first step for insurers is to understand what will be required to survive and compete as the marketplace changes. Insurers need to appreciate new technology strategies that reflect forthcoming market demands and integrate them efficiently and cost-effectively. Systems should be replaced with platforms that offer near real-time configurability without the use of expensive, hard-to-find IT specialists. As healthcare moves from the rigidity of traditional plans toward a multitude of innovative, value-based plan designs and consumer-based options, systems that are dynamic and member-centric will be required.

To survive in this new environment, insurers should demand system-wide flexibility in order to achieve the enhanced level of business agility that will be required to support changes to regulations and standards. Technology platforms that integrate traditional claim processing and benefit administration with next-generation business intelligence, predictive modeling, care management, pay for performance and consumer-based compliance incentives will be a key to success.

Adapting to the many changes that lie ahead will, no doubt, be a difficult process for many insurers. By leveraging next-generation technology, healthcare organizations will be able to take advantage of new market opportunities, achieve greater efficiencies, enhance transparency and improve customer service.

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Advancing Care Management

By Nandini Rangaswamy, CFO and executive VP, ZeOmega

Although care management has not been discussed as the means to effect change, it will emerge in 2010 and beyond as one of the most-promising and effective ways to deliver on the goals of healthcare reform. Care management as a concept, of course, is not new. What is new is the shift in approach and the technologies that make it feasible. There is emphasis on integration of information, collaboration between payers and providers, and communication with members.

In the last few years, there has been a push toward integrated utilization, case and disease management. Although payers have realized some benefits from integration through improved efficiency and reduced errors, they recognize there are further gains to be realized by proactively identifying high-risk members, engaging them at the right time and eliminating gaps in care. Payers can glean vital information on a member's health by integrating and analyzing claims, pharmacy, lab and diagnostic data housed in disparate systems. This information can be leveraged to drive rules-based care-management work flows. Tightly integrating the three components — analytics, rules and work flows — can revolutionize care management and shift the focus from collecting data to addressing quality issues.

Tight integration between care analytics and rules-driven care-management work flows is enabling precise and timely interventions, resulting in better outcomes and savings. As Medicare, employers and other purchasers hold payers more accountable for quality and costs, health plans and providers will increasingly rely on such integrated solutions to demonstrate value to clients.

Payers and providers alike are considering care-management models, such as patient-centric medical homes. Integrated provider portals, in-built messaging, discussion boards and other tools that facilitate collaboration will become critical for deploying these models.

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Web-based Applications

By Andrew Hurd, chairman and CEO, Carefx

Healthcare organizations (HCOs) have talked up portals for years, although much of the discussion has centered on clinical and patient portals. Now, however, a growing number of HCOs have begun to focus on how to provide authentic services to clinicians, patients and consumers, and facilitate health-information exchange within local communities via portal-based systems.

HCOs are looking for solutions that provide their clinicians and physicians with unified access to a patient's complete medical history, drawn from multiple encounters with multiple clinicians within the community, no matter where the data is stored, its format or native application. Providers want to maximize their technology investment by connecting to existing data sources and applications, integrating information from episodes of care, and displaying unified information, including clinician's notes, images and other data, in a role-based portal.

HCOs need to extend their vision beyond electronic medical-record implementation to create an IT environment where interoperability, service and usability can flourish. Community-based information exchanges (CIEs) can provide a foundation for enhancing patient care, safety and quality by delivering innovative solutions and functionality. CIEs can provide savings through referral-management solutions, a portal-based tool built on the CIE foundation that creates a streamlined, patient-centric and accountable process for tracking referrals.

In the years ahead, organizations will reach beyond CIEs to blend cornerstone applications such as patient access, revenue cycle and clinical applications into a seamlessly integrated whole, incorporating clinical care, management and research. Infrastructure-platform services, such as virtualization, database, network, storage, security and integration, will be augmented by application-development services for data representation, semantics and managed data redundancy. As a result, clinicians will experience a new array of services — from work flow, process management and linking of content to processes, to semantic interfacing, inter-enterprise interoperability and collaboration.

Expect HCOs' IT shopping lists to change considerably in 2010. They will increasingly seek out interfaces, APIs and Web-service layers to support portal and composite-application development, data integration, work flow and business-process management and reporting. HCOs are also likely to get more involved in composite-application development through the assembly of application assets, such as service-oriented architecture, packaged and custom applications, Web services and software as a service.

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