A new era promises better outcomes
By Elizabeth Hart, November 2011
BPM systems are the best decision for decision-support software.
Growing healthcare complexity and rising consumerism have come together to create a greater need for better decision-support tools – ones that are relevant, accessible and keep users actively engaged. Whether it’s clinical support software or consumer-oriented applications, today’s decision-support tools must be expertly designed to reflect the needs and preferences of specific users – promoting appropriate content via the right communication channel – so that optimal decisions happen. This is particularly difficult with consumer-based tools where the vast needs and profiles of users are so varied.
Advanced business process management (BPM) technology and analytics are driving significant progress and innovation in healthcare, specifically with decision-support functionality. These technologies provide intelligent and personalized navigation to individual consumers, tailoring and simplifying complex decision making by accessing and assessing customer information, company objectives and real-time data to dynamically drive decisions across a myriad of processes.
For example, benefit selection, which can be intelligently conducted through BPM-powered Web sites by health plans moving to retail business models, is one of the most common deployments of decision-support tools for healthcare consumers. During open enrollment, as individual healthcare purchasers flood portals to investigate plan choices, BPM systems automatically collect pertinent information about each consumer from all back-end systems to guide and personalize the sales experience and increase sales-close ratios. Demographic data, claims and authorization data, service information and previous sales-inquiry data are instantly assembled and analyzed by the system. Using predictive analytics, the systems then compare the data to other known patterns of successful sales transactions to generate the best sales experience for the consumer, including portal designs, product offerings and transactional navigation tailored for best fit.
For instance, the system might guide a young adult shopper to a Web site that highlights low-cost product options and showcases gym memberships, dating clubs and other features known to influence plan selections for recent college graduates. Decision-support is further enhanced through system-driven content personalization. If the system discovers that the shopper is diabetic by prompting with questions during the on-line session or from existing customer data, it will display product comparisons that include coverage reviews of in-home glucose monitoring devices or insulin brands on and off formulary. Akin to leading retailers such as Amazon.com, health plans now are using analytics to share information on what has interested similar shoppers, in this case diabetics (Which endocrinologists are in network, and whose practices are closest to the shopper’s home and work?) to further enrich the decision-making process.
By seamlessly orchestrating process with context and balancing decision rules between consumer need and company objectives, BPM systems not only increase customer value and satisfaction, they guide users to make better choices. The key is pushing the right content at the right moment, in the context of each specific interaction and user. Users need not waste time searching for best-fit information because the system does it for them, accelerating and improving final outcomes. This is quite powerful in the clinical space where the rules are more complex and the decisions more risky.
Decision support is not new to the medical field, but it is certainly not pervasive either. Legacy decision-support tools have serious limitations. They are generally inflexible (taking every user down the same, single path), they focus primarily on historical trending and it’s hard to keep them current with changing clinical protocols. User adoption and decision outcomes are subsequently suboptimal.
The convergence of increased EMR usage, advanced BPM technology and analytics heralds a new era for clinical decision-support tools. More data is being codified in EMR systems and can be made actionable by BPM systems. With its inherent integration capabilities, BPM systems easily collect data from multiple disparate systems and then apply analytics and rules to the data to inform next steps, automating processes wherever possible. This is particularly useful in informal and extended delivery systems such as ACOs which do not typically share common technology platforms.
What’s more, new information and content is easily incorporated, particularly through the use of adaptive analytics which facilitates automated learning in the system so that content presentation and consumer choices are continuously fine-tuned for each individual user. Several healthcare organizations are now authoring their own clinical rules in BPM systems, allowing physicians and other business users to personalize the protocols for their own use. Codifying the rules in BPM systems makes them more visible and manageable, making them easier to change and keep current with new medical knowledge.
Despite advancements (current and potential) in clinical decision-support software, the area of most immediate opportunity is with the non-provider population, where technology adoption is generally less challenging. Optimization of ICD-10 coding for claims and provider contracting is ripe for BPM-driven decision support, where users will be guided to choose from numerous relevant ICD codes within their specific process. The BPM system would then track the outcome of each user’s decisions, apply adaptive analytics to assess impact (lost revenue, cost, etc.) and improve guidance and suggestions to be provided to future users facing the same situation.
Another place where advanced decision support has huge potential is in engaging consumers, particularly in the areas of disease management and health and wellness programs. In fact, whether you are a health plan, provider, pharmacy benefit manager (PBM) or another healthcare company, the best approach to staying, or becoming, a trusted healthcare advisor today and safeguarding customer loyalty is to help individuals develop their own knowledge to make their own healthcare decisions. By providing essential data, sorting and processing complex information and guiding users through the process of decision making, today’s decision-support tools are improving patient knowledge regarding treatment options, plan choices and provider selections, creating realistic expectations, reducing frustration with decision making and stimulating people to take a more active role in their own healthcare.
Technological advancement has brought intelligence to decision support, which promises improvement across numerous areas – clinical, administrative and personal – that can lead to improved health and reduced costs. By providing process orchestration, advanced analytics, real-time decision making, system integration and optimized channel delivery, BPM systems are the best decision for
Elizabeth Hart is principal, healthcare industry solutions, Pegasystems.
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