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Collaboration Starts With PayersPayers play a pivotal role in the adoption of EHRs A r t i C l eEveryone agrees: Interoperability will improve the management of patient information across thehealthcare ecosystem. Yet only a fraction of healthcare organizations currently use electronichealth records (EHRs). As the shift takes place, payers find themselves at a crossroads wherethey must ask themselves: What steps can we take today to foster greater collaboration in our ownorganizations, while accelerating the move to an interoperable healthcare infrastructure?Patients can and do choose to get care from whomever they want. Choice allows patients to selectcaregivers or other providers based on their proximity, bedside manner, quality and capability,specialization, or any other factor that matters to them. But without some means of interoperability,choice leads to fragmentation of the healthcare experience. Fragmentation results in errors,duplication, lack of coordination, and many other problems. That’s bad for everybody—for patients,for physicians, and for payers.In a world that’s moving toward interoperability—where health information can be exchanged anda consumer’s medical information made portable and available to his or her clinicians—it makessense that someone lead in the establishment of a new healthcare infrastructure. Lest one forget,the transformation isn’t about standards or technology or systems: it’s about patients. It’s aboutgiving them the ability to have an active role in managing their own health and wellness.With this in mind, healthcare payers are uniquely positioned to play a critical role in the adoptionof EHRs. They are the only participants who manage all aspects of care delivery—from funding tobenefit payment, to patient and member information management. It’s time for payers to rethinktheir processes and, in many ways, to redefine their roles.Payers can immediately leverage existing silos of data to create new consumer-centeredstrategies—strategies that put consumers at the center of their own healthcare experience.Comprehensive systems and tools are available today to help payers consolidate data, sharecommon information across applications and departments, and speed transactions that cut acrossfunctional areas, effectively streamlining business processes. Fundamentally, however, these toolsdo so much more than eliminate paper-intensive processes: they effectively provide a foundation forcollaboration inside and outside of payer organizations, while offering payers an opportunity to leadthe nation through the information age.Paving the Way to a Collaborative FuturePayers must constantly answer the question, “How do I respond to the needs of today whilepreparing for the future?” The answer is not beyond reach. All the pieces of the puzzle are alreadyface up on the table, just waiting for someone to assemble them.Unquestionably, payers are performing a juggling act. They must reduce costs while at the sametime working to improve the safety, affordability, and quality of healthcare. At the same time thatthe regulatory environment is becoming more restrictive with HIPAA and more stringent privacyregulations, consumers are increasingly demanding greater access to their personal information.This is just one example of the immediate, competing priorities payers must consider as they strivefor operational efficiency while taking care not to alienate the people who ultimately pay the bills.Last year the National Coordinator for Health Information Technology, David J. Brailer, issued arequest for information (RFI) that asked for input in developing a new standard for care. The goal ofthe RFI is to provide a strategic framework for developing an interoperable infrastructure to enableelectronic health records. Although specifics of the architecture and standards have yet to bedefined, concerns about privacy have the government pushing for a decentralized architecture thatdoesn’t require a centralized repository for health data. This puts the onus on the public sector toadopt standards for interoperability, and the implication is that payers will take the lead.Logically, a standardized EHR starts with healthcare payer organizations. They have the mostcomprehensive financial and claims data on their members or patients. But until they use standardformats for collecting, accessing, and sharing patient information, interoperability in healthcare will Pivotal CRM | Article
be impossible to attain. Although some payers have already payers to provide more options, such as HSA and HRAbegun to shift their focus from streamlining transactions to accounts for greater flexibility and discretion over howmanaging information, every payer now has a window of members use their healthcare benefits. By taking advantageopportunity to standardize data and mitigate the potential for of CRM, payers can leverage technology investments to makeintrusive federal involvement on a mandated basis. EHRs readily available, while enhancing the products and services they offer their members.CrM is Becoming increasingly Critical Payers can impact the quality and efficiency of healthcare“Strategic Planning Assumption: Through 2007, 75 percent through the adoption of interconnected electronicof healthcare payers will implement CRM strategies communications to securely share coverage, plan options,that affect applications, technologies, and processes to costs, and eligibility. By allowing payers to communicateoptimize customer access (speed and convenience), lower directly with consumers, CRM offers a great deal of promisecustomer service costs, or improve revenue and profits (0.8 in engaging consumers and enhancing collaboration betweenprobability).” payers and members. Consumers stay informed. Members—Gartner, “Predicts 2005: Healthcare Payers Face Changing can make choices for themselves. Payers benefit fromVendor Market,” J. Young, C.E. Burghard, J. Galimi, November 18, administrative efficiencies.2004. CRM can help payers respond to consumers and members inSilos of information—where one system supports back-office a meaningful manner: When someone calls, they will receive aadministrative functions such as billing, while another supports level of service not often found in healthcare today. In additionlead generation, a third supports enrollment, a fourth supports to personalized service, it can help payers track and managerenewals, and so on—means data is highly underutilized. the products and services consumers demand, ensuringPayers need a framework to bring these silos together and payers can continue to respond more rapidly and effectivelyprovide a common way of storing and accessing data, with desired options, even at the point of sale.enabling them to deliver a consistent consumer experienceacross every channel. As they move to consumer-focused Fully integrated with CRM systems, an easy-to-use onlinebusiness strategies, customer relationship management self-service portal can allow members to access their(CRM) technology has become increasingly critical to their personal EHR, look up coverage and eligibility information,success. select benefits, enroll in new packages, or make changes to their profiles. By providing member access to self-serviceSuccessful CRM is predicated on the assumption that applications through a web browser, payers will significantlyconsumer information can be easily accessed throughout a accelerate the enrollment, screening, and renewal processes.payer organization. The ability to use the same information indifferent ways across the organization—by sales, marketing, Building an Adaptive Payer Organizationand underwriting, for example—creates deeper insights into The pressure is on for payers to move to information-based,the relationships payers have with their individual members collaborative business strategies. To forge new paths, payersand improves the overall effectiveness of the entire “front- need to think strategically about how technology impacts theiroffice” operation from lead management to enrollment to workflows, with information-sharing being the most criticalrenewal. CRM also provides a tremendous opportunity to component.develop a standardized format for capturing data such ashealth status and other baseline information (e.g., eligibility, In healthcare today, payers have to do more than managemembership data, and claims information) that directly their business; they need to manage change. They must befeeds into an individual’s EHR. This information provides able to adapt processes and business models with increasingthe core details necessary for patients and providers to regularity. Creating the right foundation enables them tounderstand health status, and for healthcare providers to offer leverage technologies that can be quickly and effectivelyrecommendations for treatment. introduced into such an architecture.CRM can help payers build, understand, evaluate, and act Flexible CRM technology facilitates the integration ofon deep relationships with members and prospects. It also applications, including back-end systems. It also allowsenables them to collaborate with brokers online, in real time. payers to bring their own applications together with those ofCRM not only helps payers increase productivity, dramatically other enterprises and enables them to be more responsivereduce costs, and drive efficiency, but provides brokers with to consumer demands. The goal is that with any change inthe tools they need to simplify the sales process, streamline their environment, including the introduction of standards forquoting, and automate renewal processing. Collaborative nationwide interoperability, payers will be able to adapt rapidlybusiness processes and applications enable all participants to and effectively—both today and in the long term.contribute to your organization’s success. Connecting people,transactions, and data to online business processes takes the Collaboration Best Practicesquality of healthcare delivery to a higher level. Collaboration is a business imperative. Payer organizations need to position themselves for the future. What can they doPower is Shifting… to the Consumer now to prepare? Here are the basics:There is a seismic shift in power to consumers, who are • Start at home: Concentrate on business process. Take ademanding more responsive products and services from good hard look at processes, understand them, and bepayers. Success in reaching a larger member base requires prepared to redesign them and automate them. Start by Pivotal CRM | Article