Showing posts with label Healthcare. Show all posts
Showing posts with label Healthcare. Show all posts

Tuesday, October 21, 2014

HIPAA Compliance: A Document Management Approach

Key Healthcare Challenge:
To comply with Compliance for the Health Insurance Portability and Accountability Act (HIPAA).

HIPAA Background:
The Health Insurance Portability and Accountability Act (HIPAA), and its enabling regulations, ensures patient information and records are protected and maintain their integrity.

This requires healthcare organizations to control the use and access to a patient’s private identity and medical information.

HIPAA defines regulations for:
  • Electronic healthcare transactions
  • Health information privacy
  • Security requirements
  • Unique identification for providers
  • Unique identification for health plans
  • Enforcement procedures 
Solution:
Document Management for Electronic Medical Records

Implementation:
  • Simple and easy to implement
  • Replaces paper patient records and archives with immediate ROI
  • Enables physicians to maintain current work practices:
    • Does NOT require any menu-driven patient information input workflows
    • Can use current paper-based note taking during office visits
    • Provides flexibility to access patient charts immediately at remote locations
  • Can also be implemented in concert with a formal EMR system
    • Link external information (lab reports, correspondence from specialists, signed consent forms) to EMR records
Features:
  • Security
  • Audit trail
  • Reporting
  • Electronic Payment Standardization

ROI:
  • Access and quality of care: users report very significant gains in fast access to patient information.  
  • Reduce costs associated with copying and retrieving health information. 
  • Ensure aspects of system are compliant. 
  • Health information is more tightly controlled, while at the same time more accessible to those who need it. 
  • Data is protected. 
  • Flexible and Scalable
    • Small Medical Practice Applications:
      • Electronic patient records
      • Billing, insurance EOB
    • Personnel records
    • Hospital Applications:
      • Patient records and consent forms linked to EMR system
      • Accounts Payable
      • Billing
      • HR and credentialing
      • Purchasing and supply chain

What does it mean to all healthcare organizations?
Regardless of where patient information originates - scanned from hard copy, faxed, e-mailed, PC-based or mainframe-based - Document Management Software solutions provides a secure repository that can track all aspects of patient information.

Ritesh Sujir is a Delivery Manager in the Testing Practice at Prolifics. He is an accomplished project management professional with 14+ years of experience working with Fortune 500 clients. Ritesh specializes in all aspects across project management and is accountable for the development and maintenance of project plans, risk assessments, and status reports. His recent experience includes clients in the Banking, Retail, and Healthcare verticals.


Monday, September 8, 2014

Adding IT Value to Evolving Business Models

Executive Summary:
Change has become the new normal across industries. The healthcare industry is dealing with changing market dynamics and is only now realizing the full impact of the Affordable Care Act. The financial services sector is facing growing regulatory challenges on one side and the opportunities offered by the recovering global economy on the other side. The US retail and B2B banking sector is under the impact of changing customer preferences vis-à-vis mobile banking. US Retailers are also dealing with domestic “low price” challengers and the avenues offered by the investment opportunities in the emerging economies, especially in the e-commerce sector. Manufacturers have the need to optimize the production and supply chains in order to lower costs. This article explores how effective IT decision making could help firms deal with the constant flux in their business models.

Healthcare:
The market dynamics in healthcare is changing, as the firms involved understand the true impact of the Affordable Care Act. There is increased competition because of insurance exchanges and the existing market shares are being disrupted (see exhibit 1).The reimbursement models are being updated, the healthcare networks are evolving and the Medicare market is expanding as more baby boomers retire. Hospitals are revamping their service delivery models to better improve patient outcomes and insurance companies (payers) are trying to negotiate better contracts with hospitals (providers) and formulate the most optimal benefit plans for patients. Under such a scenario, it’s critical for both the payers and providers to understand the evolved preferences of the old and new clients/customers. Do customers prefer a high deductible plan with wide coverage or a low deductible plan with narrow coverage? What type of group insurance are the employers demanding with geographically diversified work force? Are more employees telecommuting to work and if yes, have their insurance needs changed?

The second key aspect is to re-evaluate the firm’s business value. How can I drive better business value in the changed landscape? Are we targeting the correct market segment? Are our plans/benefits still relevant? Are our claim adjudication systems capable of meeting the new SLA’s? After deliberating on the above questions, the firms have to assess the capabilities that need shoring up. Creating a rules based, flexible reimbursement, network, contract and benefit management systems and having a better control of the business processes by automating them will help the insurance companies. Since the changes are continuous, it’s beneficial to set up a Service Oriented Architecture within the enterprise and better integrate the disparate source systems. Firms can deal with changes better when a service oriented enterprise is created.

Exhibit 1:
Financial Sector:
As the global economy recovers from the financial crisis of 2008, it presents both challenges as well as opportunities. Various regulatory requirements put in place such as Basel III, Dodd Frank Act, Simpson-Bowles Plan etc., to prevent a repeat of the financial crisis force significant changes to the business model of the financial firms. A KPMG study on the impact of regulations on the financial services sector predicts a high impact on the net income of the firms (See exhibit 2). With these regulatory changes, firms have to update their IT systems to better capture critical data. Firms are better off undertaking an effort to optimize their IT infrastructure, overhauling their enterprise application security, enhancing their digital user experience interfaces to capture additional data and migrating and modernizing their IT applications. These efforts could be staggered to prevent disruptions to the everyday business but are very critical to effectively comply with regulatory requirements. 

The recovery of the global economy also provides new opportunities for growth to the sector. As new business models are discovered and new market segments identified, the firms have to put in place business processes and rules to capture those segments. Digitizing business processes and rules gives better control to the firms and the required flexibility to deal with any future changes.

Exhibit 2:  


Banking:
The new retail and B2B banking customer is increasingly conducting his/her transactions via the mobile application. As per a McKinsey & Co survey, today 65 percent of customers interact with their banks through multiple channels. Human interactions are generally reserved for more complex problems: only 25 percent of agent phone calls are inquiries that could be serviced in other channels. Banks that do not provide the seamless banking experience to customers across various channels – branch, mobile and web – risk the possibility of losing out the customer’s business to other banks that provide a seamless experience. Effective mobile strategy that provides banking value to the customer and also provides banks an ability to cross sell products to the consumer similar to a physical branch is needed. Banks need to adopt cloud mobile development platform such as IBM Worklight to quickly create mobile applications and roll it out to the end consumer.

In a B2B setting, banks that can quickly set up new accounts and add/update financial products to the banking business customer can capture additional market share. The sales representatives should be able to present the product information and capture customer information on a tablet. Designing and selling new financial products that offer convenience to the businesses will provide the competitive edge to the banks.
 
Retail:
US retailers are being challenged over price by “online only” retailers such as Amazon and other competitors that are offering e-commerce channel. The retailers are struggling to reduce high costs due to big investment in stores. A key method to reduce high inventory costs is to have an integrated supply chain visibility and to be able to sync the merchandize ordering with that of supplier inventories. Also retailers can no longer have fulfillment channels in silos. There is a need to integrate the fulfillment channels and provide visibility across – a consumer should be able to add a desired product to their wish list on the website, review that product in store, purchase the product in store or place an order online and receive the product. The product return procedures should be similar irrespective of where the product was purchased. In order to provide the new business value, the retailers need to transform the customer digital experience, better integrate their source systems and modernize their IT applications by moving them into new platforms.

 E-Commerce provides an exciting opportunity in the emerging markets. As per RESEARCHANDMARKETS study, the e-Commerce industry in India is expected to grow at a CAGR of 40%, from US $ 5.9 billion in 2010 to US $ 34.2 billion in 2015E. An India based e-Commerce retailer, Flipkart, recently raised $1 billion in fresh funding. Amazon is increasing its presence in India as well. The emerging middle class of the developing economies provides a huge opportunity for the retailers. The new consumers with disposable income favor purchases of latest technology products, mainly electronic goods, over the internet. There is a significant margin that could be captured here. These new markets provide additional area of growth for those retailers with global ambitions. The retailers should fortify their e-commerce offerings and build a strong supply chain integrated with their e-commerce sites both over the web and mobile. The proliferation of smart phones in emerging economies also provides a huge opportunity in the m-commerce space. The mobile development strategy is critical to capture this opportunity.
 
Manufacturing:
With increased competition from global competitors, US manufacturers face a growing need to optimize production and reduce costs. It is more critical than ever to identify the core strengths in manufacturing and outsource any parts that are better off supplied by a supplier with a low cost. The manufacturers need to constantly evaluate available supply chain options and choose the most cost effective option. As per a KPMG survey, many manufacturing executives (49 percent globally; 54 percent U.S.) admit that their companies currently do not have visibility of their supply chain beyond Tier 1 suppliers. Moreover, only 9 percent of the 335 global respondents of the 2013 KPMG survey say they have complete visibility of their supply chains. This number is even lower among U.S. executives, with only 7 percent claiming complete supplier visibility (see exhibit 3). Adopting a robust Business Analytics and Decision Management solution is a key lever in the changed landscape. Using a business analytics and reporting software such as IBM Cognos provides the manufacturers with access to real time data on production capacity, inventory management, supplier inventories, budgeting, forecasting etc., so that  more informed decisions could be made.

Exhibit 3:


Conclusion:
While updating the business model to better deal with the changing landscape is a challenge, overhauling and effectively implementing an IT ecosystem will help smooth the journey to a great extent. Taking the help of advances in IT will help to reduce the productivity disruptions caused while modifying the current business model. Choosing a trusted IT business partner that can provide holistic IT services will also go a long way in alleviating this pain.

To learn about how Prolifics provides business value to clients around the world, visit www.prolifics.com.



N.R. Vijay is a Solution Architect in the Business Process Management division of Prolifics. He has over 10 years of consulting experience across domains such as Retail, Healthcare and Banking. Specializing in technology, management concepts and enterprise strategy, he is focused on change management and process improvement initiatives. He co-authored a whitepaper titled "Improving Customer Loyalty through Business Process Optimization and Advanced Business Analytics"

Thursday, June 12, 2014

Prolifics Employee Showcase: Alan Shemelya, VP of Healthcare Business Development

Alan Shemelya is the Vice President of Healthcare Business Development and is responsible for growing Prolifics’ healthcare services and solutions for customers around the world. With more than 30 years of experience and thought leadership in the Healthcare industry, Alan has accomplished an impressive list of milestones over the course of his career and is passionate about not only helping businesses achieve success but also making significant strides in patient care.

Commitment to Healthcare
Alan’s passion for the healthcare industry began as a young child after a trip to the hospital. His interest grew in college when he wrote a thesis on healthcare finance. During this project, he realized that hospitals were manually driven in just about everything they did on a daily basis and were operating 10 years behind. From registration to billing, automated processes simply did not exist.

It was at this time that Alan recognized an opportunity in the industry. Throughout his career, his work has always been driven by a consistent mission: finding ways to improve the care of sick children.

The Road to Prolifics
Alan joined the Prolifics team in March 2014. Over his career, he has worked with a number of leading healthcare information technology (HIT) and consulting companies in Sales, Product Development, Marketing and Implementation of EMR, Revenue Cycle and ERP solutions. Prior to joining Prolifics, Alan provided his leadership and expertise at HCA/Parallon, Xerox/ACS, Allscripts and McKesson.

Alan is driven by his motivation to provide innovative IT solutions for the provider and payer markets, specializing in improving patient, provider and payer communications, business process enablement, and outcomes. With Alan’s expertise in the healthcare industry, experts will have the experience, skills and knowledge necessary to deliver in this highly complex industry, aligning innovative and proven solutions to solve clients’ business goals.

Innovation & Thought Leadership
Alan has written articles on the redesign of business processes and advancement in technologies that enable the automation of workflow decisions impacting both providers and payers. He has been a featured speaker with the Southern Healthcare Administrative Regional Process (SHARP) and has been on the National Speakers List for the Healthcare Financial Management Association (HFMA). Below is a list of articles that Alan has published throughout his career.

HFMA ANI, 2009
HFMA Georgia Meeting, 2010
HFMA Patient Friendly Billing – Accessibility of Data

The Future is Bright
When asked, Alan selected the following three words to describe Prolifics: agility, intelligence, responsibility. He finds these characteristics as key drivers for success in building innovative healthcare IT solutions.

A Recent Journey
Alan recently participated in the AIDS/LifeCycle 2014 bike ride. This is a fully supported, 7-day bike ride from San Francisco to Los Angeles designed to raise money and awareness in the fight against HIV/AIDS. This event delivers a life-changing experience for thousands of participants from all backgrounds and fitness levels united by a common desire to do something heroic. Prolifics proudly supports Alan and this worthwhile cause!



Alan Shemelya is the Vice President of Healthcare Business Development at Prolifics. He is responsible for growing Prolifics' healthcare services and solutions for customers around the world. Alan has 30 years of experience and thought leadership in the Healthcare industry, specializing in Sales, Product Development, Marketing and Implementation of EMR, Revenue Cycle and ERP solutions. As an industry expert in the healthcare financial arena, Alan has written articles on the redesign of business processes and advancement in technologies that enable the automation of workflow decisions impacting both providers and payers. He has been a featured speaker with the Southern Healthcare Administrative Regional Process (SHARP) and has been on the National Speakers List for the Healthcare Financial Management Association (HFMA).


Friday, April 25, 2014

Case Management and Business Process Management – Benefits to Healthcare Payers

Executive Summary:

Impact is one of the eagerly awaited events of the year, the main reason being the slew of products and new features that are introduced by IBM. The application of new products and features to solve real world problems, demonstrated by solutions implemented at some of the prominent fortune 500 firms, makes every penny spent attending the event worth its value. The big product offering I am looking forward to in this year’s event is the Case Management features embedded with Business Process Manager (BPM) capabilities, thus making the processes truly smarter. Application of flexible, intelligent Case Management capabilities combined with the visibility, control and integration capabilities that BPM provides would be interesting to watch. This is even more valuable in the current setting of the Healthcare sector.

Need for Case Management in Healthcare:

With all the changes happening in the Healthcare payer sector in lieu of regulations and increasingly tough insurance market, now is the need more than ever to have flexible, smarter processes. The need of the hour is to continuously monitor market trends, identify insurance products that are not cost efficient, refine the market strategy, create flexible customized products and introduce the products within the shortest possible time to market. The best employees of Healthcare payers, with years of invaluable domain knowledge behind them, are better off applying their best judgment and making prudent decisions during the critical business processes than spend time in a swivel chair (duplicating data entry in multiple systems).

Case Management, with its feature to provide the user with the ability to review documents and choose a workflow depending on the case, can be a valuable asset.  For example, a claim review specialist reviewing a request for claim authorization, is better off reviewing the applicable benefits, claim pricing at one place in a single system with all required document images, rather than logging into different benefit systems and pricing systems, searching for the applicable benefits and pricings and performing the authorization review. After the review, the claim review specialist could choose to kick off a medical code review workflow or a payment approval workflow depending on the case. This flexibility, combined with the process visibility and legacy system integration capabilities offered by BPM could end up as a blessing. Robust document management capabilities provided by Case Management helps provide the user with the complete picture and reduces any time needed to develop a customized solution.

Case Management, BPM, Decision Management and Advanced Data Analytical capabilities combined could even lead to new business models, products and services for the Healthcare payers.

Smart people in organizations deserve to work with smarter processes and this new offering promises to provide that.

All in all, it sure is an exciting time to be in Vegas.

Next week, Prolifics will be a Platinum sponsor at IBM Impact 2014, where our team will be showcasing our BPM solutions and recent successes. If you are planning to attend IBM Impact, be sure to visit Prolifics at booth #401 or schedule a one-on-one meeting with one of our experts.

To learn more about Prolifics’ BPM solutions, visit www.prolifics.com or connect with N.R. Vijay.



N.R. Vijay is a Solution Architect in the Business Process Management division of Prolifics. He has over 10 years of consulting experience across domains such as Retail, Healthcare and Banking. Specializing in technology, management concepts and enterprise strategy, he is focused on change management and process improvement initiatives. He co-authored a whitepaper titled "Improving Customer Loyalty through Business Process Optimization and Advanced Business Analytics"


Wednesday, February 12, 2014

The Future of Healthcare: A Roadmap to Overcoming IT Challenges in a Changing Regulatory Landscape

Executive Summary:
Business organizations in a variety of industries face hardships and pain points when faced with a change. It’s especially hard when it’s a forced change through government regulations. The Affordable Care Act (ACA) presents one such challenge to organizations in the healthcare sector. This blog entry sheds light on some of the key challenges faced by healthcare payers while trying to conform to the ACA regulations and a few effective ways of dealing with them.

Affordable Care Act (ACA) - The ACA or the healthcare reform act introduces a few regulations that impact the healthcare providers (health insurers) such as:
  • Ability to accept group and individual enrollment information from a state or a federal insurance exchange website (without the insurers having the authority to reject any of these groups or individuals)
  • Cap on the percentage of premium amount that can be spent on advertising and administrative tasks
  • Expanded Medicaid eligibility – more consumers (up to 133% of poverty level) eligible for Medicaid
  • Reduced deductibility caps and new tax on healthcare payers depending on their market share

Challenges to Healthcare Payers - These regulations present quite a few challenges to the healthcare payers:
  • Need to define health plans for the state or federal exchange that can reduce costs to an optimum level, since the payers can no longer pre-screen the enrollees
  • Need to reduce turnaround time for setting up customer accounts
  • Ability to deal with increased volume of individual and small business customers
  • Keep their product networks flexible to deal with competition and sudden increase in costs
  • Continuously update their business rules related to enrollment, benefits packing, provider contracts, provider networks, provider demographics, reimbursement


Pain Points in Facing These Challenges - Clients face significant pain points in facing these challenges:
  • A combination of manual and system processes that present a lack of visibility & control
  • Legacy systems that are not flexible to adopt to the new changes
  • Many business rules that are currently enforced manually or distributed across multiple systems
  • Lack of coordination among the different functions within an enterprise

Impact of Failure to Deal with Challenges - If the healthcare payers fail in their attempt to effectively deal with these challenges they could face a few consequences:
  • Loss of market share due to long turnaround time for insurance and contract enrollment
  • Loss of revenue due to cost ineffective networks
  • Government fines imposed due to failure to meet the regulations

Effectively Dealing with Challenges – The healthcare payers can follow a few steps proactively to be better prepared to deal with current as well as future regulatory changes:
  • Identify process owners, map their current end-to-end processes across the enterprise, clearly map functional hand offs within processes, collect Key Performance Metrics (KPI), defineroles and responsibilities
  • Harvest existing business rules that are manually enforced and those that are embedded across systems
  • Analyze current state processes to identify - redundant activities, scope for automation, patterns across process and consolidate them into a single process
  • Create future state processes that are optimized by consolidating roles, eliminating bottlenecks
  • Establish clear expectations on the process hand off between functional units across enterprise
  • Identify and implement technology such as IBM BPM (Business Process Manager) to automate “non-value” adding manual activities, integrate source systems with process via web services, manage the workflows and gain visibility into the process (e.g.: Supervisor having the ability to view the status of workflow tasks assigned to their team)
  • Consolidate and centralize business rules into a single system by utilizing a technology such as IBM ODM (Operational Decision Management) and automate the interaction between BPM enabled process and ODM business rules
  • Empower the business users to directly maintain business rules in ODM and hence reducing the downtime due to IT maintenance
  • Introduce data analytics software such as IBM Cognos to collect customer impacting data such as claims settlement time, customer issue resolution, time to market for new plans etc., and measure the ROI from process improvements in terms of data 
  • Continuously monitor the process metrics and update the automated process. A BPM and ODM enabled business process provides the flexibility needed to continuously deal with changes




Conclusion:
By proactively adopting an automated process and rules driven approach, Healthcare payers can build flexibility into their business critical processes. Achieving visibility and control of their processes will provide them the ability to deal with the pain points resulting from change effectively.





N.R. Vijay is a Solution Architect in the Business Process Management division of Prolifics. He has over 10 years of consulting experience across domains such as Retail, Healthcare and Banking. Specializing in technology, management concepts and enterprise strategy, he is focused on change management and process improvement initiatives. He co-authored a whitepaper titled "Improving Customer Loyalty through Business Process Optimization and Advanced Business Analytics" - http://www.prolifics.com/customer-loyalty-bpm-analytics.htm.



Monday, May 20, 2013

Prolifics' AJ Aronoff on Healthcare Infrastructure Demands

AJ Aronoff is a Practice Director and IBM Champion covering Application Infrastructure at Prolifics. Recently at IBM Impact, AJ was interviewed on current infrastructure demands in the healthcare industry. Specializing in solutions for the healthcare industry, AJ explains how he can help the industry understand the latest healthcare regulations. In this video, he discusses the value that IBM WebSphere Application Server (WAS) brings to the industry, and the latest advancements in WAS 8.5. In addition, AJ explains the impact mobile technology is having on the healthcare space, opening up the possibility to cut down on a lot of the paperwork as well as allowing doctors and medical staff to record information at each bedside.

View AJ's interview on Healthcare Infrastructure Demands!


Interested in learning more? Contact AJ Aronoff today - aj@prolifics.com.

To learn more about Prolifics, visit www.prolifics.com.


AJ Aronoff is the Application Infrastructure Practice Director for Prolifics and an IBM Champion for IBM WebSphere. AJ first joined Prolifics as a Developer, then specialized in WebSphere MQ. He has 25 years experience in the IT field — 17 of those years at Prolifics. As a Prolifics consultant, he has done MQ design, implementation, infrastructure, monitoring and security assignments at several large financial, insurance, retail and communication firms (Bloomberg, Credit Suisse, Deutsche Bank, DTCC, Fidelity, ITG, JPMC, Och Zif, Tokyo Marine, Pep Boys and British Telecom). He has presented on security and infrastructure at Impact, Hursley comes to Minneapolis and Palisades, and MQ User Groups. His customers use Omegamon to monitor over a thousand systems across the globe.