Information Systems in
Managed Health Care Plans
By: Jolly Pandyacc
Anthony Harding
Jitka Gruntova
Tony Mbirwe

Content
• I. Part: Introduction
• II. Part: IT Function Overview
• III. Part: Delivery Attributes of The IT System
• IV. Part: Market Trends and IT
• V. Part: Conclusion

Introduction
• http://youtu.be/9jAH9hdF0xk
• http://youtu.be/Lo_3qOejQzI
• Execution of Business and the customer experience are
nearly entirely information technology driven
• Technology enables everything from core processes, such
as claims adjudication, to consumer touch points, such as,
websites, and customer service systems, to internal
enablers, such as, employee email and medical
management enabled technology systems

What Technology Can Do
• Information technology can help reduce errors in
medications
• Use of computerized physician order entry (CPOE) can
reduce medication errors by 80%
• (foundation for e-health)Picture archiving &
communication system (PACS) eliminates need for films,
allows interaction on a global scale: savings, improved
quality & cost reductions
• Improvements in diagnosis & treatments with technology
help the quality & availability of care
• Telemedicine/telehealth: monitoring chronic diseases over
distances allows for access to care, quality of care, &
reduces costs

To The Consumer
Example-Young woman
To the consumer experiencing lower back pain
1. She visits her health plan website to research
• Insurance is not a simple her symptoms and boor for a Doctor
transfer of risk, but rather a 2. At the Doctor office she hands I.D card to the
staff member at front desk who confirms
series of interactions that are eligibility by using a interactive voice response
system.
all technology enabled 3. After visit the provider submits a claim via
claims clearing house to the insurance company
4. Claims processing system adjudicates the claim
according to the patients current benefit
5. Young woman receives explanation of benefits
in mail but is concerned with error
6. She visits website to look for information
related to claim and places to call customer
Service
7. Customer Service call is routed to a customer
service representative who then uses interface
to health plan’s internal membership, claims,
and benefits systems responding to the inquiry
documenting the interactions with the member
8. Scenario represents the pervasive nature of
Technology

Critical Internal Information Technology
Function Overview
• I.T department designs, implements, operates, and
maintains systems that perform critical core business
processes essential to day to day operation of the health
plan organization
• Must be completed efficiently and accurately on an
ongoing basis, and new efficiencies must be created to
achieve cost reduction opportunities
• Storage system must be packed with a set of interfaces
that allow other systems, such as claims and customer
service applications to access this data for processing
inquires

Products
• Products are the entities that are sold by health plans
and bought by consumers
• 2 main consumers groups in the health insurance
market-employers who offer it to employees and
individuals who don’t receive it through employers
• I.T must support the systems that manage the
individual variables for each product
• I.T solutions must facilitate the input and ultimately
store benefit levels, procedures, code information,
deductible amounts, co insurance or co pay amounts,
and other data points that determine how members
get paid

Eligibility
• Moved to IVR phone system to Web • Tape-Tape data base transfers from
based provider portals employer
• The systems are queried by providers • Or Via a secure electronic
to determine how a patient should be connection
billed at the time of service • Advance health Plans offer
• Eligibility systems are also involved in Automated tools to sales agents and
determining how to bill the employer brokers like demographic
or member information which is transmitted
• Information is loaded when individual • Maintenance phase is when
or group signs up then is put in information is updated
eligibility system (older system is • I.T must support both the
called legacy system.) enrollment, and maintenance process
• Custom feeds must be designed from
• Electronic loading-entering info on employer’s personnel system, and
secure website and password protected Interfaces must be built by customer
IVR system via secure web
• Imaging is used strict security and
privacy are used under HIPAA • Some large firms outsource but I.T
still runs it

Claims processing
• Provider network system or databases are queried to
determine whether the provider or hospital billing for
the services is part of any of the health’s plan’s network
(HMO or PPO)
• In network out of network claims
• Authorization & precertification
• HIPAA mandated standards for submission, query, and
response
• Lags behind even though physicians are starting to
grow to more modern software
• Paper fax & phone common use

Claims Submission to Health Plan
• Electronic EDI=electronic data interchange reduces
labor
• Large Hospitals=claims clearing house which
establishes electronic connections between
Physicians hospitals, billing services, and health
Plans
• Moves claims and inquires electronically among the
parties
• Large Insurance companies have outsourced manual
data checking, and entry to off shore locations

Medical Management and Predictive Modeling
• All medical management activities are supported and
enabled by I.T
• Including Decision support systems, tracking and case
management systems
• Enabled patient centric devices and interfaces like a scale
that sends congestive heart failure patients daily weight to
the health plans disease management program
• More Access better health management and better out
comes keeping the cost low

I.T Responsibility to Plan
• Creation of (PHR) Personal Health Record & more
availability through system
• Adopt EMR electronic medical record
• Must maintain data warehouse, and use
sophisticated data mining and informatics tools to
transform the raw data into information for use by
the medical management systems
• Systems must be designed so that data gathered can
be quickly and easily transformed into actionable
information

I.T Support leading practices
• Automated Creation Care Plans
• Automated routing of new participants care plan to
correct disease manager
• Ability to view claim history, and EMR (Electronic
Medical Record)
• Customer Relations Management System
• Quality Plus Program
• NCQA Accreditation Review Process
• PBX telephone system
• (transactions & code sets
• Electronic transactions

Documentation
Risk stratification
Predictive Modeling
software ranking levels
of severity
Establish outbound call
frequencies
Periodic care call for
prevention care

Provider Credentialing and Network Maintenance
• Data feed provider directories printed and online used by consumers
to make contacts
• Provider Credentialing and Network Maintenance
• Data feed provider directories printed and online used by consumers
to make contacts
• Credentialing program collects detailed information about the
provider’s medical training, certifications, and any specialties
disciplinary actions
• National Practioner Data Bank is a requirement under credentialing
• Maintenance of provider Database or file is function of Network
management
• I.T organization must design solutions and interfaces that can assist in
the collection use, and maintenance of provider Data
• Electronic communication

Challenges of I.T
Use of imbedded intelligence to help drive
reimbursement systems
Hard coding of identifiers
Provider ID field type cannot accommodate the
format of NPI

Member Service
Key Market Differentiator for IVR Systems must integrate well with
Health Plan traditional services channels like
Positive & negative experiences customer service, and tracking
Challenge since call centers, and Tracking and reporting solutions must
Web Portals is customer be deployed to identify issues and key
expectations metrics for management
Members demand accurate Sophisticated load balancing software
to help calls move from location to
information across multiple channels
location
for convenience
Outbound calls to influence members
Email & Web chat more Prominent
behavior
Self Service Channels such as online
I.T must support member services by
member Portals
integrating multiple technologies
I.T must educate so service associates
can educate members effectively

Consumerism and the Proactive Approach
• Easy to use decision support system enables the
front line to assist members in their treatment
choices
• Robust customer insights and analytics tools
• Enabling the identification and segmentation of
member populations for targeted interventions
• Enabling view of PHR

Information Systems in Managed Health Care Plans
Employer I.T Provider I.T
Portals can enable Provides method to verify
enrollment and maintenance patient eligibility
capabilities Web Portals to submit
Employers can edit claims or reconcile
employee eligibility
receivables against
View and Pay bills online
payments
Enable features for
employees to complete
initial enrollment online

Information Systems in Managed Health Care Plans
Bookers and I.T agents Member
Provide tools and Provides a way to deliver self-service
capabilities to existing customers, and
information to assist in the a way to deliver product information
sales cycle and decision support tools to potential
customers
I.T must support E-Business
initiatives by ensuring web based
solutions are complementary to other
channels
Must be in place to monitor and
correct system issues outside of
business hours

Internal Enablers
I.T organization is to manage, maintain, and service
enabling capabilities such as email, telephone, and
other communication channels for health plan
employees

Borrowing Technology
Technology from the financial service industry plays role in
payment of healthcare
Swipes Cards-is easy access to spending account funds &
relief in Account Receivables
Use of Card to verify eligibility & Co pay
Smart cards do the same thing but it holds limited personal
health record information
Providers receive timely & accurate information that
minimize bad debt
No paper work for consumer filing

Healthcare Integrity
• HIPDB- fraud Program and fraud tracking system
• HIPAA- mandate standards for electronic transactions
became effective in May 2002 (May 2003 for small health
plans)
• Privacy regulations became effective in April 2003 (2004
for small health Plans)
• National Provider Identifier-May 23 2007
• Additional measures for electronic PHI (protected health
information that is maintained in electronic media which
includes hard drives, computer disk, internet, and email

Security Standards Applicable to
electronic protected Health
 Security management process  Facility Access controls
 Assigned security  Workstation use
responsibility  Workstation security
 Workforce Security  Device and media controls
 Information access  Access control
management  Audit Controls
 Security Awareness  Integrity
 Security Incident procedures  Person or identity
 Contingency Plan Authentication
 Evaluation  Transmission security
 Business associate contracts

Delivery Attributes of the IT Systems
The Nationwide Health Information Network governance expects entities that
participate in the Nationwide Health Information Network to include elements of:
• privacy and security
• usability
• flexibility (interoperability)

1) Security and Privacy
• In order for providers and patients to have trust in health IT and
information exchange, they must be confident that privacy and security
laws are in place and will be enforced.
• Federal laws and regulations such as HIPAA and the Sarbanes-Oxley Act,
as well as state laws and regulations in some cases, mandate additional
constraints on technology and processes to ensure the security and privacy
of consumers

Statutes and Regulations
Statutes
American Recovery and Reinvestment Act of 2009 (ARRA)
This statute includes the Health Information Technology for Economic and Clinical Health Act (the
HITECH Act) which establishes the Medicare and Medicaid EHR Incentive Programs that encourage
meaningful use of certified EHRs and other health information technology (IT) to improve quality of
care.
Health Information Technology for Economic and Clinical Health Act of
2009 (The HITECH Act)
The Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part
of the American Recovery and Reinvestment Act of 2009, allocated billions of dollars for the health
care system to adopt and meaningfully use health IT to improve health. A number of provisions in the
HITECH Act strengthen the privacy and security protections for health information established under
the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA called for the establishment of standards and requirements for transmitting certain health
information to improve the efficiency and effectiveness of the health care system while protecting
patient privacy.

Statutes and Regulations
Regulations
Medicare and Medicaid Programs: Electronic Health Record Incentive
Programs Final Rule
This rule specifies the initial criteria that eligible providers must meet to qualify for the Medicare and
Medicaid EHR incentive payments, and it includes other incentive programs participation requirements.
Health Information Technology: Initial Set of Standards, Implementation
Specifications, and Certification Criteria for Electronic Health Record
Technology Interim Final and Final Rules
Under these rules, the Secretary has adopted the initial set of standards, implementation specifications and
certification criteria that are required for the certification of EHR technology.
Establishment of the Temporary Certification Program for Health
Information Technology Final Rule
This final rule establishes a temporary certification program for the purposes of testing and certifying
health IT, thereby ensuring the availability of Certified EHR Technology for eligible health care providers
seeking incentive payments available under the Medicare and Medicaid EHR Incentive Programs.

Statutes and Regulations
Regulations
Establishment of the Permanent Certification Program for Health
Information Technology Final Rule
This final rule establishes a permanent certification program for the purpose of certifying health IT.
Breach Notification for Unsecured Protected Health Information Interim
Final Rule
This rule implemented section 13402 of the HITECH Act by requiring HIPAA covered entities to
provide notification following a breach of unsecured protected health information to individuals, HHS,
and in some cases the media. This rule also requires business associates to notify covered entities
following a breach of unsecured protected health information.

HIT Standards and HIT Policy Committees Information Flow

3) Usability
• In delivering technology solutions, the IT
organization must be aware of the ultimate use of
the system; in other words:
How will the system be accessed?
What are the characteristics of the users?
• Increasing the engagement and understanding of
patients and providers may increase their
willingness to participate in information sharing
that they trust and that is private and secure,
including secondary uses of EHR data in research.

4) Flexibility
• The first priority of health IT is to enable primary care
physicians and specialist to electronically exchange lab results,
patient care summaries, and medication histories
• Health IT is also a critical tool in empowering patients. Existing
and emerging technologies allow data to flow directly to and
from the individual, wherever the individual may be. As a
result, patient interactions with the health care system are no
longer confined by the walls of the clinical setting and may
occur frequently in between visits.
• Personal Health Records (PHRs) allow patients to capture their
own health observations. For example, mobile phones with
glucometers allow individuals to track their blood sugar levels
through their mobile devices. Mobile phones and related
applications are being used in mental health to track moods and
provide therapeutic interventions with personalized messages,
exercises, and coaching.
Using these tools, individuals can become more attuned to
healthy behaviors, monitor their health, make informed
personal health decisions, and receive preventative care.

MARKET TRENDS AND
INFORMATION TECHNOLOGY (IT)
 The market research report analyses the key trends in global healthcare information
technology market, and segments it into various submarkets as per their sizes in
various geographies
 The global healthcare information technology market is estimated to be $53.8
billion in 2014
The market is expected to grow at a high CAGR of 16.1% (from 2009 to 2014) because
of government initiatives to reduce healthcare costs and the tremendous demand for
healthcare IT applications such as electronic medical records
 Information technology offers solutions for almost all the areas in the healthcare
system, including clinical trial management and clinical decision support
 Hospitals are also increasingly implementing e-prescribing systems

Consumerism
• Today’s healthcare consumers demand more information about their healthcare
providers in order to get quality services
• This has led to more need for IT to collect and disseminate data
• Data collected must be in compliance with, links to state records, consumer
feedback
• The system built must be flexible enough to accommodate structured and
unstructured data.
• IT must also support the consumerism movement by identifying ways to educate
members on their own health – primarily through online tools and information –
and supporting innovative product designs that incorporate new financial
instruments and benefit designs
• Health plans must justify the theory of consumerism to employer groups by
reporting on the success of consumerism products. Data are required to illustrate
that when more responsibility is transferred to consumers, they use health care
services more intelligently

Pay-for-Performance
• Due to increased focus on healthcare costs, health plans are
developing new ways to pay providers for services rendered such as:
-The pay-for-performance model- compensation is tied to
compliance with best practices and results achieved, not just on the
number or duration of services
• IT must support this model by crating solutions that can collect these
data from different sources, transform and load data into a storage
area, and provide access methods for reporting systems and
consumers

Plan as Financial Institution
• The health insurance industry has often looked to the financial service
industry as a role model in the evolution of the technology organization.
• This helps evaluate risk and security involved while providing care
• Consumers often bring expectations from other industries, such as financial
services. Financial services are a decade ahead of the health plan industry
in terms of delivering high-quality self-service capability to consumers.
• For example financial institutions introduced self-service Web sites and
automatic teller machines (ATMs) in the late 1980s and have quickly
evolved those offerings based on consumer demands and feedback.

Conclusion
• Evolving Information Systems of upcoming times is not so
much about delivering bits and bytes, but ―supposedly‖ rather
about delivering information, solutions (not creating
problems!), and services to support managed care
organizations.
• Physicians and those doctors who are not very familiar with
the electronic based information systems is going to face a
major challenge since they will be at the bottom of the learning
curve
• Either it can increase the efficiency and functionality of the
healthcare system or it can affect the quality of patient care
where doctors/physicians are spending more time on computer
than patients and their problems.

Conclusion - Where We Are Today
• Only 15% of hospitals have some form of computerized medication
order entry implemented. In those hospitals, physicians enter less
than 25% of the orders
• Only 10% of hospitals utilize bar-coded medication administration
at bedside. Fewer than 5% of providers use computerized patient
records
• About 80% of the estimated 35 billion health transactions each year
are conducted by phone, fax, or mail—not via the Internet. The
financial services industry spends about 8-10% on information
technology; HE healthcare industry = 2-3%
• In 2010 only 25% of physician offices and 15% of acute care
hospitals take advantage of EHRs. Even fewer use remote
monitoring and telehealth technologies.
• While many consumers access their banking information online
daily less than 10% use the web to access their personal health
information.
• http://youtu.be/NleWPN6CADE

Questions??
• Do you anticipate betterment in efficiency and
functionality of current managed healthcare
organizations?
• Will it overcome setbacks and provide more
efficiency than current information systems?
• Where do you see Information Systems in
upcoming 3-5 years?

Resources
• Geisler, E. (2008). The Role of Technology in
Healthcare Delivery. Retrieved form
www.chicagofed.org/../presentation_role_of_
technology.pdf
• Kongstvedt, P., R. (2007). Essentials of
Managed Health Care. Sundbury,
Massachusetts: Jones & Bartlett Learning.
• www.wikipedia.com