The evolution of care management systems integration: functional integration and comprehensive patient information build on the cost savings and competitive advantages introduced by technical integration

Health Management Technology, Oct, 2004 by John H. Capobianco

Within the managed care organization (MCO), systems integration efforts have typically focused on technically integrating front-end and back-end systems. IT departments have spent a lot money building best-of-breed applications and then maintaining the interaction between those stand-alone systems, and technical integration minimizes the costs of application management and administration. Creating a common back-end database and a common user interface simplifies life for the IT department, which no longer has to support the variety of operating systems, databases, fat clients and other disparate systems associated with a heterogeneous computing environment.

The second stage of systems integration evolution, however, promises an even greater level of savings and competitive advantage to the MCOs that pursue it. Beyond technical integration of care management systems lies their functional integration. Such integration creates a common data flow across individual systems such that information generated by one application feeds related applications to promote actionable information and process automation.

Similar to the IT burden relieved by technical integration, functional integration relieves the work-process burden created when highly trained care management nurses manually execute routine, nonclinical tasks.

By automating standard procedures, functional integration lets nurses focus their clinical skills on those patients who will benefit most from their services. For example, rather than task a nurse with looking up employer-specific benefit plans or manually drafting a written communication to a patient or doctor, functionally integrated systems automate this type of work and free that nurse to focus on the medical needs of the patient.

Functional Integration in Action

A functionally integrated care management system combines a number of independent subsystems or components, including:

* analytics and a predictive modeling component to evaluate providers, patients and plans;

* transactioning components to automate authorizations, referrals and communications with providers and patients;

* utilization management, disease management, case management and other components to manage populations across the continuum of care;

* clinical rules and processes components to ensure the best healthcare practices are delivered to the point of care.

Two additional features distinguish the functionally integrated system. First, it has ties to the MCO's claims system to facilitate analysis and automation. Second, it generates a consolidated record for each member. This payer-based health record (PBHR) grows over time as the MCO accrues medical claims, lab results, pharmacy data, health risk assessments, utilization management authorizations, case and disease management data, and other clinically pertinent data, which is used by all of the integrated system components.

In action, a functionally integrated system will automate much of the work that would otherwise be executed manually or perhaps be overlooked. For example, an MCO could use such a system to run analytics on its member population. The system then hands off the analytics results to the care management component for evaluation.

If the data analysis reveals a large disease population such as diabetes within a given provider's patient list, the system can tag each of the diabetic patients and their records. For a patient needing an ophthalmologist appointment, the system will update his or her PBHR with a "gap in care" notice and then score the patient for risk using other data found in the PBHR. For a low-risk patient, the MCO might want specific literature regarding diabetes and eye care sent to the patient via postal mail, and the system automatically generates that request for literature and sends it to the processing system for fulfillment. The system then flags and prioritizes the patient as "low-risk follow-up" in the case manager's workflow queue, so the case manager can later contact the patient and encourage an ophthalmologist appointment.

Meanwhile, the system will update the patient record with the gap in care and make it available to the provider at the point of care. When the patient sees his or her primary care doctor for an unrelated concern, the doctor can pull the PBHR and see the gap in care. Using the system's transactioning feature, the doctor can submit an ophthalmologist referral to the MCO and the system will automatically approve the referral--all while the patient is in the doctor's office.

In contrast to the above system example, a care management system that lacks functional integration demands human intervention at each stage of the process. After running analytics and reporting on the diabetic population, an MCO staff member must manually enter the report into the disease management system. The disease manager, in turn, passes his or her results to the individual care manager charged with patient follow-up. Similarly, primary care doctors have no automatic, systematic tool for proactively managing or monitoring their patients' disease states. If the primary care provider neglects to ask about a patient's last eye exam, the opportunity to make a referral is lost.