A Story of Partnership: HealthInsight

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myNextStep Americas 2013

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A Story of Partnership: HealthInsight

  1. 1. A Story of Partnership
  2. 2. Who is HealthInsight? ➢ We are a private non-profit organization, acting as a catalyst in the redesign of health care systems with a long track record of participation and success in the Medicare QIO program. ➢ We have been national performance leaders, piloting innovations, sharing knowledge, and promoting program advancements through the years. © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  3. 3. Who is HealthInsight? The federally-designated Quality Improvement Organization for three states (NV, NM, UT) with more than 40 years experience. Also contract with 27 other states’ QIOs to handle their appeals on weekends and holidays. © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  4. 4. What does HealthInsight do? We are experienced, successful agents for change ➢ Our current work includes serving as an: – – – – – – – – Medicare Quality Improvement Organization State External Quality Review Organization; Regional Extension Center (REC) for Health Information Technology; National ONC Beacon Community; and Community health information exchange (HIE) organization NRHI regional health improvement collaborative; AHRQ-designated Chartered Value Exchange (CVE); RWJ Foundation Aligning Forces for Quality community; ➢ Forty years experience working in the federal Medicare program.
  5. 5. Improved System Performance Relationships Payment Alignment Copyright HealthInsight 2004
  6. 6. The Quality Assurance Division Medical Case Review – improving care one case at a time. ➢ Patient and Family Engagement and Immediate Advocacy ➢ Complaints Investigation (Quality of Care) ➢ Expedited Appeal of Discharge/Termination of Service Determinations • • Process over 1000 cases monthly, more cases than any other QIO, Cover appeals under subcontracts with 27 other QIO’s and provide mitigation review for conflicts of interest cases for 21 states © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  7. 7. Appeal Example • Sally is Medicare beneficiary living alone who was recently admitted to a hospital after a fall during which she broke her hip. • The surgery went well and after a week the hospital provided her with a notice that her Medicare provided services would be terminated the following day • Sally doesn’t feel ready to go home and requests an appeal of the termination • She calls the Medicare Helpline (rings at HealthInsight) requests an expedited appeal of her discharge/ service termination notice • HealthInsight processes the appeal (requests and redacts medical records for the physician reviewer; requests and records the physician review; notifies the beneficiary and providers of review outcome; updates government system with case details; sends written notices to case parties, if required) • Sally receives a call from a HealthInsight nurse saying that her independent Physician Reviewer agrees with the planned discharge/termination of services and if she stays in the hospital she will be responsible for paying any for the services she receives after the day on the termination notice.
  8. 8. What we had? HealthInsight leads the nation in development and use of technology to support electronic case review and drive efficiency in the Quality Assurance work © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  9. 9. Our Dilemma? ➢ ➢Current – – – – application is built on Lotus Notes Medicare will not approve Lotus Notes for external web use Relies on a Lotus Notes freelancer for maintenance Can’t respond to change requests Can’t keep up with regulations updates and state specific customizations ➢ Want to scale their business to all 50 US states ➢ Expand business beyond Medicare © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  10. 10. Additional Business Challenges? • The life cycle of a review request typically lasts 1 to 3 days • HI is only paid if cases are processed in a timely manner; penalized if case processing does not meet Medicare Regulatory SLAs • Physician Reviewers must be paid regardless • All medical records supplied by Medicare providers must be “redacted” • Numerous government rules and regulations must be observed • Physicians receive and respond via email or fax; manual data entry • CMS does not allow any direct integrations; duplicate and manual data entry required • CMS still requires providers to FAX in medical documentation © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  11. 11. Lotus Notes Screenshot
  12. 12. Appeals Screenshot
  13. 13. Appeals Screenshot
  14. 14. Look-up Info Use of whiteboards and loose leaf sheets to track and keep users updated on latest information
  15. 15. Business Rules Business rules end up as reminders on various computer “sticky” notes
  16. 16. Our Solution! HealthInsight engages OutSytems to help us migrate off the Lotus Notes platform
  17. 17. Our Approach? ➢ Requirements Gathering Session ➢ Initial walk through of the old application ➢ Workflows – business process documentation – old and new ➢ Defined Sprints and Epics ➢ Based on assumptions supported by industry standards and experience ➢ Timebox of 3 months ➢ 2 full time developers ➢ 1 full time delivery manager ➢ 1 part-time engagement manager © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  18. 18. Expected Business Process © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  19. 19. High-level Architecture Support & Clinical Staff Administrator
  20. 20. Expected Feature Usage Features and Functions Used in a Typical System Source: Standish Group Study Reported at XP2002 by Jim Johnson, Chairman © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  21. 21. Actual Detailed Business Process © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  22. 22. Actual Feature Usage Features and Functions Used by Hi-Resolution ALL DAY LONG INFREQUENTL Y END OF DAY MONTHL Y WEEKLY Source: Standish Group Study Reported at XP2002 by Jim Johnson, Chairman © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  23. 23. Other Challenges ➢ PDF document manipulation (upload, merge, manipulate, preview) ➢ Inbound fax queue management and outbound faxing ➢ Automatic processing of inbound emails ➢ Specific UI requirements – ➢ ➢ ➢ ➢ ➢ ➢ Specific screen sizes User guidance that supports process flow User role business functions can overlap Lock indicators for cases Information rich pages and entry forms Users with low technology proficiency ➢ Extensive audit logging ➢ Many, many business process exceptions ➢ Support for IE8 and IE9 © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  24. 24. Was this a gamble? Source: Standish Group Study Reported at XP2002 by Jim Johnson, Chairman © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  25. 25. How we got it done! ➢ Incredible team work and work effort between business and development teams ➢ Delayed vacations ➢ Early mornings and late nights and some weekends ➢ Extreme categorization of defects and requirements for prioritization ➢ Willingness by business to live with some problems and do some things manually ➢ Compromises in functionality to simplify the design ➢ Increase of timebox by 1 month of development time for stabilization and issue resolution © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  26. 26. New HI-Resolution Application © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  27. 27. New HI-Resolution Application © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  28. 28. New HI-Resolution Application © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  29. 29. New HI-Resolution Application © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  30. 30. New HI-Resolution Application © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  31. 31. 2013 Rollout Plan Development & Testing Go Live Full Tuning Rollout
  32. 32. What we accomplished? • Migrated all business functions off Lotus Notes • All key functions can be performed in the new application • Established the baseline to which HealthInsight will be able to add: • Additional functionality - like external access for physician reviewers • Additional contracts (states) for which to process appeals • Additional types of processes besides appeals © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  33. 33. What we accomplished? • Some Statistics • Almost 170 user stories • Managed over 400 defects and change requests • Processed 1400 new cases in the first month © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  34. 34. What we learned? ➢ Having IT infrastructure in place is “critical” ➢ Things aren’t always as simple as they seem ➢ Managing timelines, competing priorities and goal conflicts ➢ The old adage of “Test early and often” still holds true ➢ Test early on the same type of equipment that the users will be using ➢ Targeting old browser versions with a new application wastes time ➢ When replacing an application, you cannot always count on some functionality not being needed. ➢ A sense of humor goes a long way ➢ Wine, port and chocolates help make up for lost sleep © OutSystems. All Rights Reserved © OutSystems. All Rights Reserved www.outsystems.com
  35. 35. Questions?

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