Payers play a pivotal role in the adoption of EHRs and increasing healthcare interoperability. Payers are uniquely positioned to lead this transition given their comprehensive view of patient care and costs. Payers can leverage existing patient data and implement CRM systems to create consumer-centered strategies, consolidate information, and lay the foundation for greater collaboration within and between organizations. This will help put patients at the center of their own healthcare while accelerating the shift to an interoperable system.

1. Collaboration Starts With Payers
Payers play a pivotal role in the adoption of EHRs
A r t i C l e
Everyone agrees: Interoperability will improve the management of patient information across the
healthcare ecosystem. Yet only a fraction of healthcare organizations currently use electronic
health records (EHRs). As the shift takes place, payers find themselves at a crossroads where
they must ask themselves: What steps can we take today to foster greater collaboration in our own
organizations, 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 select
caregivers 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 and
a consumer’s medical information made portable and available to his or her clinicians—it makes
sense 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 about
giving 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 adoption
of EHRs. They are the only participants who manage all aspects of care delivery—from funding to
benefit payment, to patient and member information management. It’s time for payers to rethink
their processes and, in many ways, to redefine their roles.
Payers can immediately leverage existing silos of data to create new consumer-centered
strategies—strategies that put consumers at the center of their own healthcare experience.
Comprehensive systems and tools are available today to help payers consolidate data, share
common information across applications and departments, and speed transactions that cut across
functional areas, effectively streamlining business processes. Fundamentally, however, these tools
do so much more than eliminate paper-intensive processes: they effectively provide a foundation for
collaboration inside and outside of payer organizations, while offering payers an opportunity to lead
the nation through the information age.
Paving the Way to a Collaborative Future
Payers must constantly answer the question, “How do I respond to the needs of today while
preparing for the future?” The answer is not beyond reach. All the pieces of the puzzle are already
face 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 same
time working to improve the safety, affordability, and quality of healthcare. At the same time that
the regulatory environment is becoming more restrictive with HIPAA and more stringent privacy
regulations, 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 strive
for 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 a
request for information (RFI) that asked for input in developing a new standard for care. The goal of
the RFI is to provide a strategic framework for developing an interoperable infrastructure to enable
electronic health records. Although specifics of the architecture and standards have yet to be
defined, concerns about privacy have the government pushing for a decentralized architecture that
doesn’t require a centralized repository for health data. This puts the onus on the public sector to
adopt 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 most
comprehensive financial and claims data on their members or patients. But until they use standard
formats for collecting, accessing, and sharing patient information, interoperability in healthcare will
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2. be impossible to attain. Although some payers have already payers to provide more options, such as HSA and HRA
begun to shift their focus from streamlining transactions to accounts for greater flexibility and discretion over how
managing information, every payer now has a window of members use their healthcare benefits. By taking advantage
opportunity to standardize data and mitigate the potential for of CRM, payers can leverage technology investments to make
intrusive 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 electronic
of 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 communicate
optimize customer access (speed and convenience), lower
directly with consumers, CRM offers a great deal of promise
customer service costs, or improve revenue and profits (0.8
in engaging consumers and enhancing collaboration between
probability).”
payers and members. Consumers stay informed. Members
—Gartner, “Predicts 2005: Healthcare Payers Face Changing can make choices for themselves. Payers benefit from
Vendor Market,” J. Young, C.E. Burghard, J. Galimi, November 18, administrative efficiencies.
2004.
CRM can help payers respond to consumers and members in
Silos of information—where one system supports back-office a meaningful manner: When someone calls, they will receive a
administrative functions such as billing, while another supports level of service not often found in healthcare today. In addition
lead generation, a third supports enrollment, a fourth supports to personalized service, it can help payers track and manage
renewals, and so on—means data is highly underutilized. the products and services consumers demand, ensuring
Payers need a framework to bring these silos together and payers can continue to respond more rapidly and effectively
provide a common way of storing and accessing data, with desired options, even at the point of sale.
enabling them to deliver a consistent consumer experience
across every channel. As they move to consumer-focused Fully integrated with CRM systems, an easy-to-use online
business 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-service
Successful CRM is predicated on the assumption that applications through a web browser, payers will significantly
consumer information can be easily accessed throughout a accelerate the enrollment, screening, and renewal processes.
payer organization. The ability to use the same information in
different ways across the organization—by sales, marketing, Building an Adaptive Payer Organization
and 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, payers
and improves the overall effectiveness of the entire “front- need to think strategically about how technology impacts their
office” operation from lead management to enrollment to workflows, with information-sharing being the most critical
renewal. CRM also provides a tremendous opportunity to component.
develop a standardized format for capturing data such as
health status and other baseline information (e.g., eligibility, In healthcare today, payers have to do more than manage
membership data, and claims information) that directly their business; they need to manage change. They must be
feeds into an individual’s EHR. This information provides able to adapt processes and business models with increasing
the core details necessary for patients and providers to regularity. Creating the right foundation enables them to
understand health status, and for healthcare providers to offer leverage technologies that can be quickly and effectively
recommendations for treatment. introduced into such an architecture.
CRM can help payers build, understand, evaluate, and act Flexible CRM technology facilitates the integration of
on deep relationships with members and prospects. It also applications, including back-end systems. It also allows
enables them to collaborate with brokers online, in real time. payers to bring their own applications together with those of
CRM not only helps payers increase productivity, dramatically other enterprises and enables them to be more responsive
reduce costs, and drive efficiency, but provides brokers with to consumer demands. The goal is that with any change in
the tools they need to simplify the sales process, streamline their environment, including the introduction of standards for
quoting, and automate renewal processing. Collaborative nationwide interoperability, payers will be able to adapt rapidly
business 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 Practices
quality of healthcare delivery to a higher level. Collaboration is a business imperative. Payer organizations
need to position themselves for the future. What can they do
Power 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 a
demanding more responsive products and services from
good hard look at processes, understand them, and be
payers. Success in reaching a larger member base requires
prepared to redesign them and automate them. Start by
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3. looking at the current versus desired state, and map the
workflows that support collaboration.
• Break down internal barriers: Many healthcare payers have
internal departments that may not communicate effectively
with one another. Quantifying the value that organizations
aspire to achieve, and identifying clear success metrics
make it real for everyone involved.
• Exploit your information assets: Integrate consumer-facing
channels and deliver more options to consumers—in the
right format, at the right time.
• Invest in open technology: Improve service levels
by removing siloed access to information. Invest in
applications and technologies that aggregate data and
provide a consistent 360-degree view of members.
• Start in one area and evolve over time: Consider a phased
implementation; it will produce short-term, tangible
results to fuel future initiatives. Payers can validate
the implementation of a collaborative framework by
starting internally—beginning with sales, marketing, and
underwriting—and can later add applications that extend
accessibility to their broker network and consumers.
Collaborative approaches to the delivery of payer services will
be rewarded in the marketplace.
Through the implementation of more agile technology and
interoperable platforms, payers can respond to consumer
demand for more responsive products and services today,
while also paving the way for adapting to future change—
quickly and cost-effectively. Payers who don’t act today to
build a collaborative infrastructure will find themselves left
behind and at a huge competitive disadvantage in terms of
quality, membership, and operational efficiency. Payers who
act today, on the other hand, will lead the pack and have a
major impact on the nation’s future healthcare infrastructure.
learn More About Pivotal CrM
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