Surviving the enterprise integration war: HCOs can improve efficiency and reduce operational costs by implementing an operational data store for real-time views of transaction-related data – Data Management

Surviving the enterprise integration war: HCOs can improve efficiency and reduce operational costs by implementing an operational data store for real-time views of transaction-related data – Data Management – healthcare organizations

Helen Gurevich

There is an enterprise integration war being waged by a multitude of clashing forces. XML versus EDI and its variants–X12, HL7, ACORD and NCPDP, to name but a few–tends to dominate the scene.

At the same time, specific technologies–Web application servers, Web services, transformation and routing, data warehousing, business process management, open network architecture and service-oriented architecture–have their own conflicting philosophies and devout supporters.

All claim to be the sole solution when it comes to integrating information throughout an enterprise. Each believes it can outdo the others and win the day for healthcare organizations (HCOs).

How can beleaguered health plan executives and IT managers cut through the fog of war to determine what is the best integration approach for their organizations?

One answer may be an operational data store (ODS), which is like a miniature data warehouse, but much more agile. It makes no difference to an ODS if it is storing data that originated as XML, EDI or just about any other format that may be generated by applications deployed by HCOs’ IT departments or their partners. An ODS’ relational schema supports data in their most granular form, including dimensions containing details of the service line segments and every single data element.

As a data repository, an ODS captures and stores for rapid reuse data generated in critical operations and transactions such as an eligibility inquiry or a patient’s claims submission. The data collected by an ODS is not static, as in a warehouse, but constantly updated to allow for quick and targeted queries: When did the patient file his claim? When did he resubmit it? What is the coordination of benefits (COB) status?

The duration for which transactional data exist in the ODS is carefully controlled by the retention period parameters used for the database maintenance process. It could be a transaction’s insert/update/delete date and time stamp, transaction status, archiving considerations, master warehouse maintenance consideration or a combination of several business criteria.

Meeting the Challenge

The ODS concept has been developed and realized in the process of HIPAA implementation work at healthcare payer organizations across the country during the last two years. HCOs have been looking beyond HIPAA deadlines to gain competitive-edge and bottom-line efficiencies through e-health initiatives that intelligently mine data and processes, consolidate legacy systems, enable subscribers to tailor, choose and qualify insurance policies online via Web services and Internet ports, automate employers’ insurance enrollment plans and streamline claims autoadjudication.

To support these new initiatives, HCOs need to get at and make use of data such as patient/subscriber profiles, billing and accounting data that would otherwise be found in a static condition in a traditional data warehouse. They need to manage this critical transaction-related data minute by minute as it flows through the organization throughout the day. The data needs to interact with multiple adjudication systems, to be sent to partners and to be split, combined, repackaged, routed and securely delivered.

Here are typical business challenges that can drive HCOs to consider an ODS:

Multiple, disparate, back-end adjudication systems for specific types of healthcare claims based on different lines of business (e.g., emergency room, ambulance, behavioral health, chiropractor, rehabilitation, Medicare).

Frequent billing reversals for adjustments of payments based on additional information, billing corrections and remittance advice balancing errors.

Management requirement for visibility into operational data to monitor key business indicators such as: real-time statistics for number of claims successfully processed, rejected and pending due to adjudication issues awaiting claims attachments; number of claims over a predetermined amount paid; average time for claims adjudication and payment; number of eligibility and claim status requests; and large enrollments statistics.

Requirement for splitting individual transactions to separate Medicare, COB and large-employer-specific HMO plan claims for processing.

Need for repackaging claims that have been handled in separate sections to create new envelopes for further routing, tracking and auditing control numbers.

Requirement for all error-handling facility for exceptions processing, clearinghouse errors management, provider notifications, manual analysis and adjustments.

Need for handling legacy systems’ COB claims, forwarding claims to different payers for secondary payments.

“Extra” HIPAA data: incoming data that has no home in the current back-end legacy system.

“Missing” HIPAA data: the need to transmit data that does not exist in any current system and can be sourced only from incoming transactions.

Even without such aggressive initiatives, the typical HCO confronts large and complex data streams flowing across a multitude of diverse applications. The challenge is to collect, structure, protect, manage, analyze and view that important data on demand. When these goals are met, the result is faster processing, happier “customers” and partners, greater IT efficiency and significantly reduced operational costs.

Pragmatism Prevails

In the recent IT past, the competing format demands of diverse applications associated with the challenges above would produce nothing but chaos for HCOs, their IT managers and business executives.

However, an ODS is capable of establishing peaceful coexistence among the opponents in the enterprise integration war. By providing a temporary resting place for data that is important to collect but isn’t ready yet for a data warehouse update, creating a special place for data that has potential long-term significance but no home in the corporate data warehouse, and enabling the tracking of dynamic data–regardless of their format–an ODS can support critical business decisions without forcing HCOs to choose sides. Thus, the HCO can emerge a winner, even as the enterprise integration war continues.

Helen Gurevich is the director of healthcare solutions, Industry Solutions Unit, of Ascential Software Corp., Westboro, Mass.

COPYRIGHT 2004 Nelson Publishing

COPYRIGHT 2004 Gale Group