Market consolidation has left payers with legacies of multiple, disparate systems and inconsistent data sets. Many plans have systems that exist in separate silos for various business functions; the systems are unable to routinely communicate essential data between them. This is evident in claims systems that were not designed to receive clinical information.

Business-intelligence technology platforms that are infused with clinical and healthcare expertise provide integrated business and clinical intelligence that make possible linking the right people with the right information to make faster decisions about coverage, treatment and plan design. Analytics with outward-facing capabilities to engage stakeholders — employers, clinicians and members — are also needed so they, too, can make data-driven decisions that are both medically sound and cost-effective. Future business intelligence systems will:

Offer true enterprise-wide solutions: One central source of business intelligence is needed for the whole organization. This data should be easy to use and readily available. Stakeholders throughout an organization should be able to query and receive up-to-date metrics for their programs.

Performance metrics should be accessible for all providers. Solutions also should be customizable to reflect the culture and specific needs of an organization. Most of all, they should be robust enough to provide actionable analyses.

Use right-time data: Next-generation analytics will include the most-current data and methodologies. Claims completion factor data, for example, might reveal an early spike in costs that is projected to exceed the expected variance for a certain procedure. Drilling down further into the data, a medical director might find the cause and be able to address it quickly. If, for example, costs for total knee replacement were up because of many clotting complications in one physician group, the medical director could direct that group to guidelines on the proper use of prophylactic anticoagulation. Plans need tools that depict a situation in as close to real-time as possible — and analyses that produce actionable results.

Incorporate clinical and claims data, with capability for preset alerts: When a newly enrolled patient is found to be diabetic, that clinical data should immediately trigger an alert to the plan. This would prompt nurse managers to quickly introduce disease management or other services aimed at keeping the patient healthy and out of the hospital. Similarly, a plan should be able to monitor, for example, the number of emergency department visits for acute respiratory distress. If those visits spike among pediatric patients, plan managers should be able to drill down through the data to see the cause of the problem.

Integrate evidence-based medicine: Clinical rules and clinical intelligence need to be integrated with business analytics. The rapid incorporation of claims and clinical data provides an opportunity for cost-effective care and improved outcomes.

If data creates a more-complete profile of a specific population, plans can design targeted benefits. If a system includes regional and national guidelines and quality benchmarks, a plan is able to meet requirements for regulatory and quality reporting more readily. All of these uses have a measureable return on investment.

Rose Higgins is vice president of care-management solutions at McKesson Health Solutions. For more information on McKesson solutions:

May 2010

The Source for Healthcare Information Systems Solutions