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Capgemini

Enterprise application integration enables information sharing, transaction processing, andcollaboration across the health industry. Payer-provider collaborations form the hub and providethe access points for transactions among the other constituents.

Enterprise application integration (EAI) is the process of transforming a collection of isolated and independent software applications into a collaborative stream of interconnected and automated processes. From a technical perspective, EAI initiatives can lead to application consolidation, systems replacement, and process automation that help to eliminate redundancies, inconsistencies, and inefficiencies across the organization. Such efforts can, in turn, result in server and network infrastructure enhancements across business units and subsidiaries. EAI transformations cascade across organizational boundaries.

EAI initiatives are becoming increasing vital in supporting payer-provider connectivity. Business processes across payer and provider organizations are both tightly integrated and highly interdependent. In some respects, business-to-business (B2B) connectivity between payers and providers has resulted in a much tighter knitting of processes than is normally achieved via EAI and business-to-employee efforts internal to a health care organization. Quality of care, operational efficiencies and effectiveness, and financial stability are directly affected by these interdependencies. Enterprisewide EAI efforts within each health care organization are necessary to provide the foundation for payer-provider collaboration throughout the health care industry.

EAI Addresses Pain Points

EAI is a technical solution that can help payer and provider organizations address several business imperatives. Issues that health organizations can address through EAI include:

• Financial pressures – Proliferation of disparate IT systems and associated business processes lead to organizational inefficiencies and ineffectiveness that impact financial performance. Manual processes have proven to be costly to health care organizations. This, coupled with the increased cost of health care, has created a need to automate and manage health care processes more efficiently. An inability to identify and pinpoint delays in the accounts receivable cycle and a cumbersome, prolonged denial management process, as well as inefficient coordination of benefits processes, have led to operational cost overruns and cash flow issues.
• Patient safety and clinical outcomes – Quality of care and financial and operational problems result from redundant, incomplete, and inconsistent medical records. Many medical treatment and prescription errors result from manual and insufficient controls across health care organizations.
• Regulatory compliance – HIPAA, state, Sarbanes-Oxley, and other regulations demand data consistency, security, privacy, and process controls across an organization’s systems as well as within payer-provider interactions.
• Accreditation requirements – Accrediting organizations such as NCQA/HEDIS for health plans and JCAHO/ORYX for health care providers require that organizations gather and report clinical, operational, and financial performance. This data must be compiled from across the organization.

Figure 1. EAI’s Central Role (and Interdependencies)

The Benefits of EAI

EAI offers the potential for improved quality of care, increased operational efficiencies and effectiveness, and reduced health care costs. In addition, EAI provides specific benefits to each constituent in the health care industry. EAI beneficiaries include medical practitioners, groups, members, patients, chief executives, brokers and agents, and internal areas such as legal departments.

For medical practitioners, EAI helps to streamline practice management. It provides access to more accurate, complete, and consistent medical records, reduces medication and treatment errors, and reduces the need for costly malpractice insurance. It also helps them more easily comply with regulations and accreditation requirements.

Both provider and payer organizations need to consistently and effectively manage health care information in order to provide long-term, sustained benefits to their members and patients. That ability is enabled through EAI. For groups, members, and patients, this results in reduced health care costs, reduced time spent in appeals and grievances, and reduced paperwork through shared health care information. It expedites health care treatment scheduling and servicing, improves quality of care (including reduction in medication and treatment errors), and empowers consumers to manage and control their health care options, records, and dollars.

Integrated health care systems and data across health care organizations provide CFOs with the ability to both control and reduce operational and health care costs. This is further enabled via business intelligence capabilities for tracking, analyzing, and reporting on financial trends and factors. EAI also results in operational efficiencies, reduction in appeals, grievances, and legal costs, which all contribute to an improved bottom line for the CFO.

For COOs, EAI offers the potential to replace disparate, costly, and inconsistent automated and manual processes. It helps streamline operations from up-front business interactions to back-end transaction processing mechanisms and associated systems. It also helps organizations share operational processes across the health care industry in order to streamline health care interactions and reduce operational and IT support costs.

EAI can provide a foundation for enterprisewide compliance with corporate policies and procedures, accreditation requirements, and government regulations (e.g., HIPAA, Sarbanes- Oxley Act, Gramm-Leach-Bliley, Patriot Act, state regulations). Legal departments can benefit from EAI by requesting the incorporation of mechanisms for controlling and monitoring adherence to these principles. EAI can also deliver a single point of control and an auditing mechanism for security and privacy matters and common payer-provider processes such as appeals and grievance management.

For CIOs, EAI efforts offer additional benefits:

• Server consolidation. Extensive EAI efforts across complex multi-tiered heterogeneous environments can benefit from server consolidation offerings. The CIO can benefit from operational and maintenance cost savings associated with managing simplified server infrastructures.
• Application Component Reusability. EAI efforts provide CIOs with the opportunity to incorporate common processing mechanisms and components (including portlets and Web parts) across the organization in order to enable reusability, flexibility, interoperability, and maintainability. This can be achieved through either IT transformation of applications developed in-house or through the implementation of certain large-scale applications.
• Cost savings from better application management;
• Standardization of disparate transaction processing mechanisms; and
• Business intelligence. EAI and B2B enable extensive business intelligence capabilities through data integration across the enterprise and with external business partners.

Collaboration Opportunities Through EAI

EAI provides the technical foundation for payer-provider connectivity and collaboration in several areas, including:

• Enterprise resource planning (ERP);
• CRM;
• Practice management system integration;
• E-Prescribing, computerized physician order entry (CPOE), and electronic medical records (EMR);
• HIPAA transaction implementation;
• Health care information systems (HIS) integration; and
• Enterprise collaboration portals.

Enterprise Resource Planning

ERP software is used to integrate back-end processes associated with human resources, payroll, finance, and materials management. This amalgam of processes serves as the foundation upon which supply chain management and other enterprise initiatives can take form. ERP packages can provide real-time access to cost and performance data across diverse and complex health care organizations. ERP suites that are integrated to both health care delivery and claims processing systems enable streamlined performance of those processes, as well as collection of metrics on quality and cost-effectiveness of medical care.

Figure 2 shows how a provider’s back-end ERP suite may be integrated with a claims management package and health care delivery systems via EAI mechanisms. It also shows how a claims management system interfaces with a payer’s adjudication, benefits management, and payment systems via B2B mechanisms. In addition, the integration of disparate and isolated payer applications via EAI is shown in stark contrast to the tight coupling of modules within the provider’s ERP application suite.

Figure 2. Conceptual view of ERP, EAI, and B2B Relationships

Customer Relationship Management

CRM is the process whereby customer service is continuously provided, monitored, and improved upon via an integrated suite of sales, marketing, and servicing systems. CRM, in the health care space, focuses on the acquisition, retention, and servicing of health plan groups or members (payer perspective) and patients (provider perspective).

As health care organizations implement self-servicing options and move toward consumer-directed health care (where the members are empowered with the tools to control and manage their health care options, accounts, and funds), CRM becomes increasingly critical to payers and providers alike. Health plans and providers require the ability to monitor and influence health plan options and consumer behavior in order to provide the best quality of care at the most affordable cost, while retaining members and patients.

Yet most CRM implementations function as isolated islands that have not provided payers and providers with the ability to effectively analyze, report, and collaborate on the clinical and cost-effectiveness of their members’ health plan options. In order to address this information chasm, analytics packages have been utilized in concert with EAI efforts related to data warehouses maintained through automated feeds to operational systems and databases (including those of the CRM packages). For those organizations that have invested in a CRM application, analytical capabilities are provided in new releases of such products. On the other hand, health care organizations that have not invested in these application suites are more likely to purchase stand-alone analytics packages with a richer offering of features and open architectures for applications integration. CRM coupled with analytics capabilities enables payers and providers to collaborate on common quality of care and financial concerns related to health care treatment.

Practice Management System Integration

There are nearly 900 vendors of practice management systems with varying degrees of functionality. Some address the needs of large practice groups and hospital systems. Others are marketed to smaller physician groups. EAI needs exist across all of these packages to one degree or another. A couple of common areas of need are the integration of practice management systems with clinical systems and lab information systems. Providing these capabilities is important to payer-provider interactions in monitoring and assessing treatment effectiveness, costs, and health plan coverage during episodes of care. The degree of connectivity features for payer-provider transactions also varies across practice management systems, resulting in different degrees of application integration that is required with each organization’s transaction management software.

E-Prescribing, CPOE, and EMR

E-Prescribing (e-RX) is the process by which prescriptions are authorized and placed by physicians via electronic means.

The primary impetus for e-prescribing is that the majority of medication errors occur during the order entry process. Through the integration of CPOE, the maintenance of an EMR, and e-prescribing functionality, a robust set of features emerges, including:

• Real-time patient eligibility determination;
• Real-time drug benefit coverage determination;
• Drug coverage rules (formulary) access;
• Integrated eligibility, formulary, and benefits decision-making tools;
• Drug utilization evaluation (including drug-drug interaction, duplicate order prevention, and drug condition matching);
• Patient drug and treatment history; and
• Prescription renewals, which make up 75 percent of prescription requests.

Capgemini – in partnership with Microsoft, Allscripts (the recognized leader in e-prescribing), HP, and Intel – has developed solutions around the AllScripts TouchWorks product and Microsoft .NET servers. These solutions provide full e-prescribing functionality.

HIPAA Transaction Implementations

HIPAA transaction implementations require integration to enable X12N transaction processing with external business partners. The required integration is between internal transaction processing systems and operational systems (i.e., claims, accounting, adjudication, eligibility, and benefits management systems of health plans). For example, from a payer perspective, claims transactions (i.e., 837 X12N) require integration between an organization’s transaction processing mechanisms, adjudication engines, and claims and accounting systems.

HIS Integration

HL7 transactions are utilized to facilitate EAI across provider health care information systems. These transactions can also be used in creating integrated payer-provider business process integration. For example, an HL7 registration transaction generated from an admission, discharge, and transfer system could be leveraged to automatically generate an HIPAA X12N transaction for patient eligibility checking (270/271 transaction pair) by passing common data elements from the HL7 transaction to the X12N transaction.

Enterprise Collaboration Portals

An enterprise collaboration portal is a front-end extension to an organization’s legacy systems and B2B solutions. These portals are implemented utilizing a service-oriented architecture where multiple views to back-end systems are interconnected via a common workflow scenario supporting the diverse needs of an organization. Each view is implemented as a Web part (or portlet) with integration to back-end systems via multiple technical mechanisms.

From a health plan perspective, such solutions can take one of five self-service perspectives, including provider, member, group, broker, employee, or some combination thereof.

An example of a portal for payer-provider interactions is a claims correction and denial management collaboration portal. A claims correction portal serves as a nonintrusive and integrated extension to an organization’s claims transaction mechanisms, adjudication, and claims processing systems. Such a portal is implemented as a secure extranet access point where providers and payers can effectively collaborate on the correction of failed, rejected, and pended claims. The portal can be customized to the unique workflow, communications, collaboration, document management, legal, financial, operational, and technical requirements of both the payer organization and providers in the payer network. Features of such a payerprovider solution are likely to include:

Payer-managed rules engine for selecting, displaying, correcting, reviewing, approving, routing, revalidating, and reposting of claims;

Views controlled via settings related to security, privacy, processing point (transaction validation vs. adjudication edits), error codes, organization type (i.e., provider or payer), department, users, and roles;

• Batch claims correction of transactions failing WEDI SNIP and payer-specific validation rules;
• Batch submissions of technical corrections to a transaction engine;
• Corrections to pended and rejected claims from back-end adjudication systems;
• Resubmission of business corrections to adjudication systems;
• Appeal and dispute management;
• Adherence to regulations, company policies, and contract administration control procedures;
• Tracking, analyzing, and reporting on claims rejection trends and financial implications; and
• Dashboard views displaying statistics related to submitted, rejected, pended, disputed, resolved, and corrected claims.

Conclusion

EAI initiatives across the health care landscape are both diverse and varied, yet all contribute to industrywide collaboration toward improving quality of care, operational efficiencies and effectiveness, and health care cost management.