Post ACA Survival Kit

Transcription

1 D R I V I N G C O L L A B O R AT I O N : Post ACA Survival Kit A Best Practice Model, and Reference Cases, for HIT Executives Tasked with Winning in Healthcare Chaos. 1

2 Agenda Healthcare 3.0 (Drive Innovation, Engage Consumers, Maximize Value, and Transform Care) 4 Aptitudes Model (Capability Integrator, Agile Thinker, Smart Modernizer, Services Enabler) Capability Integrator Taking advantage of what is available Agile Thinker Moving at clock speed Smart Modernizer Investing Smartly - same money multiple benefits Service Enabler Moving Forward Summary 2

3 Speakers John Kelly, Principal Business Advisor at Edifecs, a nationally recognized health information exchange expert. Kelly provides strategic consulting to Edifecs healthcare customers and specializes in information exchange and applying the principles of supply chain integration to the healthcare delivery lifecycle. His wide-ranging experience includes serving as CIO of healthcare network provider NaviNet, director of ebusiness Architecture at Harvard Pilgrim Health Care, and managing director of his own Health IT consulting firm. John Kelly Principal Business Advisor WEDI Board Member He Serves on the Boards of Director for WEDI and the Massachusetts Health Data Consortium. References m_source=exacttarget&utm_medium= &utm_ content=what-does-it-take&utm_campaign=hls- Newsletter Vik Sachdev Vice President of Products Vik Sachdev is responsible for the technology roadmap, design and delivery of Edifecs Smart Trading and Community product lines. Vik has more than a decade of experience in healthcare, and supply chain and integration in both product management and engineering. 3

4 Innovators in Healthcare Driving DRIVING Collaboration COLLBAORATION HEALTHCARE FOCUSED Empower health plans to automate, streamline, and accelerate key business processes by optimizing and improving their partnerships with providers. Healthcare transformation will require dynamic integration, information coordination, and partnership management to control costs, increase revenue and build healthier communities. Customer first innovation model, proven by 20 years of reinvesting in new solutions to meet the demands of the radical transformation impacting healthcare APPROACH 1996 Data-Driven Capabilities Risk-Driven Capabilities Value-Driven Capabilities 2018 Smart Trading Automate costly administrative processes and integrate clinical systems Ensure Compliance Simplify mandate and regulation compliance for a competitive differentiation Optimize Revenue Accept risk with confidence with analytics-based revenue integrity and visibility. Integrated Record Build a complete patient record from value-based partner networks Care Interventions Improve care coordination and interventions using evidencebased rules and insights Manage Programs Design, operationalize, and scale value-based reimbursement programs 4

5 P A T H W A Y S T O P A R T N E R S H I P S Healthcare 3.0 Challenges 5

6 U N C E R T A I N T Y Healthcare 3.0 The rapid digital transformation of healthcare is revolutionizing the industry in unpredictable ways and requires a dynamic response. T I M E F R A M E 6

7 Are You Ready for the Known Changes? The move from pay for service to pay for value is creating more IT challenges when harnessing data from key relationships. Pay for Service vs Pay for Value Single service Episode of care Single claim transaction Involves many transactions Simple payment rules driven by fee schedule Complex payment rules driven by contract performance Provider often outsources payment and monitoring Provider more likely to analyze internally Key goal: Call reduction Key goal: Transparency 7

8 Are You Ready for the Un-Known Changes? As the healthcare world changes and leaders look for direction to predict the future of their business. Sometimes the assumptions are wrong. nhealthcare&utm_medium= &utm_content= news &utm_campaign=am 8

9 Foundation for Change A day in life of healthcare CIO: reducing costs, managing risk and driving topline growth. Drive Innovation Engage Consumers Transform Care Maximize Value 9

10 B U D G E T Managing to Costs Delivery budget may replace EOL projects but not all objectives? VBR World: V=Q/C where C is fixed Value-Added Services Clinical Interventions Home Health Legacy or EOL Replacement Connecting Patient Platforms New Standards (IHE, HIE, FHIR) Care Coordination Population Health Services Behavioral Health Alternative Health LTC Community Agencies Microsoft (BizTalk) SAP (SyBase) Clinical Interoperability (HIE, EMRS, CMs) ehealth Patient Portals Delivery Budget HIEs ehealth EMRs 3 rd Party Billers Facilities Specialists Oracle Sun (JCAPS) PCP C A P A B I L I T I E S 10

11 Survey Questions Industry Challenges What would you select as your biggest HIT challenge? 1. Funding for technology innovation 2. Adoption of consumer-based applications 3. Transforming current methods of care 4. Scaling alternative reimbursement models 11

12 P A T H W A Y S T O P A R T N E R S H I P S 4 Aptitudes Model 12

13 The Legacy HIT Professional In the past, companies tended to focus on a simple IT strategy. As healthcare shifts from payer and provider systems to the modular, interconnected organizations, the responsibilities are also evolving. A Cost Cutter The Maintainer Legacy Replacer The Dreamer Capability Integrator Agile Thinker Smart Modernizer Services Enabler 13

14 P A T H W A Y S T O P A R T N E R S H I P S Capability Integrator 14

15 The Capability Integrator Must be able to bring in new capabilities, reconfigure them, and modernize outdated systems. Defined: All innovation will not occur inside the Healthcare organization. Successful HIT group must be able to incorporate new capabilities, reconfigure existing and dispose of outdated systems. Use what is available without designing from scratch. 15

16 Examples Example: CMS ProPublica has used CMS data to build our Treatment Tracker, Prescriber Checkup and Dollars for Docs tools, among others. 16

17 The Capability Integrator Use cases that are already in practice. Basic Sophisticated Open & Free NPI lookup and validation against NPPES API Latest drug adverse effects information from Open FDA Healthdata.gov Capability Integrator 3 rd Party Build member 360 into CRM such as Salesforce. Master Provider Referential Database, containing accurate and up-to-date information on 6.5 million health care providers by Lexis Nexis 17

18 Use Case Integrating claims processing with member data in Salesforce. 18

19 P A T H W A Y S T O P A R T N E R S H I P S Agile Thinker 19

20 The Agile Thinker Create a culture of experimentation, quick turnarounds and incorporating complimentary technologies. Defined: Ability to think, prototype and deliver new products or new product enhancements at clock speed. Become a digital upstart and champion new ideas with fail fast mindset. 20

21 Examples Who is doing this already? Hackathons. - Health Datapaloza - Stanford Health++ Hackathon - MIT Grand Hack 21

22 The Agile Thinker Use cases that are already in practice. Basic Sophisticated Incorporate new complimentary technologies to existing system. Example, elastic store provide quick search and ad-hoc data analytics. Agile Thinker Think of new ways to connect and collaborate. Example, FHIR as a way to connect with provider EMR systems to exchange quality metrics and care coordination. 22

23 Use Case 23

24 P A T H W A Y S T O P A R T N E R S H I P S Smart Modernizer 24

25 The Smart Modernizer Replace legacy to deliver more and put a framework for growth and reuse. Define: The ROI to replace EOL or legacy systems such as JCAPS or Sybase Is difficult to justify but the investment cannot be avoided. Smart Modernizers are long term frugal, they have dual goals to deliver new functionality and build a base for future growth 25

26 Example Who is doing this already? State Medicaid's who are incorporating clinical data and administrative data for population management and VBC Blues who are adopting wrap around and phased migration from legacy to new. Starting with non-automated transactions and clinical data and then transitioning existing transactions 26

27 The Smart Modernizer Use Cases already in practice Basic Sophisticated Leverage compliance mandates as a way to bring in new technologies Operating rules Phase I, II, III, and IV. Smart Modernizer Data Centric Approach Consolidate data processing Manage data life cycle Make data accessible and re-usable for multiple applications avoid silos, avoid stale data, process data on wire and deliver new applications 27

28 Use Case 28

29 P A T H W A Y S T O P A R T N E R S H I P S Services Enabler 29

30 The Service Enabler What does future payer organization look like? Define: Next generation health plan will have to be a coordinator and facilitator taking on new responsibilities to deliver premium customer experience. In order to remain competitive they will have to become the single trusted point for customers healthcare regardless if the service is for dental, medical, vision, pharmacy. 30

31 Examples Who is doing this already? New health insurance companies Oscar, Collective Health. While the business model is being worked out, they have proven the market is ready for concierge experience. Regional health plans who have been structuring themselves into different LOB (lines of business) while providing a seamless frontend experience to their members 31

32 The Service Enabler Use Cases already in practice Basic Sophisticated Creating bridges between the enterprise and external companies which become part of company s ecosystem Build a scalable framework for Cross Enterprise collaboration and process flow 32

33 Use Case 33

34 P A T H W A Y S T O P A R T N E R S H I P S Summary 34

35 Survey Questions Industry Challenges Which aptitude best describes you and your current situation? 1. Capability Integrator 2. Agile Thinker 3. Smart Modernizer 4. Services Enabler 35

36 Key Focus Areas As the healthcare world changes and leaders look for direction, guidance, and new ideas, we offer proven value-based solutions to support our client's ability to: Success in Healthcare 3.0 Capability Integrator Agile Thinker Smart Modernizer Service Enabler Drive Innovation Leverage what others are doing to catalyze disruption throughout your organization Fail fast and often Take a phased approach, extend before replacing Connect and share liquid data with all stakeholders Engage Consumers Correlate aggregated data to orchestrate a concierge experience Meet them where they are. Be time, location and mindset relevant Build APIs, make data liquid Member centric cross enterprise processes across a complete journey of care Transform Care Connect the dots (ER, Results, PCP) to build a complete picture of collected health data Share information in a manner that naturally integrates with the intuitive workflows Deploy targeted, actionable alerts and interventions at the right time and place Delivery is distributed and effective. Collaboration and coordination are key Maximize Value Embrace other peoples data and applications to extend your own Place multiple small bets and rapidly nurture which ones succeeds Be long term frugal lay the foundation for reuse later while maximizing the value of investment now Organize your stakeholder contracts around a integrated data community 36

37 Q/A and Resources Thank you for attending. If want to further this discussion please contact us directly or through your WEDI contact. WEDI 2017 Los Angeles May 15 More Info Available Edifecs.com Modernization WP Resources ngformpublic/view?id=7b1b c alue-based-care-drives-smart-modernization 37

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