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The Road to Transformation
             Ensuring your infrastructure will meet business vision
                             today and tomorrow




December 7, 2010                                          © Blue Slate Solutions 2010
About Blue Slate Solutions


 Clientele
     4 of the top 20 health payers including 7 BCBS plans
        2 of them in the top 3
 Experience
     100+ healthcare-specific projects
       25+ different healthcare entities

             Liz Gaudet                                    Dave Read, CISSP
             •   Healthcare Leader at Blue Slate           •   Blue Slate CTO and Chief Solution Architect
             •   26 years multi-payer experience           •   20+ years tech leadership experience
             •   Business process and strategy focus       •   Strategy and technology focus
             •   Passionate about your success             •   Passionate about governance and security




                                                       2
                                                                                                 © Blue Slate Solutions 2010
Our client


    40 year old US payer, 2500+ employees across multiple
      locations serving several million subscribers



        Will current architecture serve future business vision?




                                How can we surpass our competition?




                                    3
                                                                  © Blue Slate Solutions 2010
Two tracks; one destination




                   Current State       Applications

                 Grounding             Technologies
               Strategy                Organization
           Business                    Technology




                                   4
                                                      © Blue Slate Solutions 2010
Technology Methodology




                 © Blue Slate Solutions 2010
Technology methodology



   Discover IT organization’s
   alignment and skills


   Examine technology
   capacity and flexibility


   Assess application
   functionality and data



                              6
                                  © Blue Slate Solutions 2010
Architectural maturity model: transformational change


                                   Standardized                            Business
                 Business Silos                      Optimized Core
                                    Technology                             Modularity




                                                      Companywide        Plug-and-play
                    Local IT      Shared technical
 IT Capability                                        standardized      business process
                  applications       platforms
                                                     process or data        modules




                  ROI of local                       Cost and quality
  Business                                                              Speed to market,
                    business      Reduced IT costs     of business
  Objectives                                                             strategic agility
                   initiatives                         operations




                                          7
                                                                          © Blue Slate Solutions 2010
Systems and stovepipes

       Department 1 – Imaging, Workflow                               Department 2 – Portal and eServices
         LOB 1
                               Inbound Paper                            MYSE                Core Services (data tier)
           Doc WFE             Appeals




           Inbound Paper –     Inbound CORR                            DDI (current)        DDI (rewrite)
           Claims              EDI




                               Inbound Paper–                          Escalation Inquiry       Notification Email                INV Tracking
           Inbound Paper
                               Finance                                 Tracking                 Tracking                          System
           COB



           Inbound paper –     Inbound Corr –
                                                                       ADI-C#
           Enroll              Other                                                            Call Center Inquiry               FIN Tracking
                                                                                                Tracking System                   System



         LOB 2
                                                                       Portal Services
           Claims - Initial      Extract                   NTI                                  Medical Review
                                                                                                Tracking System

                                                           NT2
                                                                       LOB 1 Appeals
                                                                       System
           Claims Processing     NT-Agg                                                         COB Tracking System
           secondary                                       NT2A




                                                                                                            DWH- Informatics
              EDI Systems                  Mainframe Systems          Call Center Technology
                                                                                                              ETL
                                             Mainframe                  IVR / VRU
                 EDI Gateway
                                             Programming

                                                                                                              Analytics & Stats
                                             Other Corp
                                             Tools...




                                                                  8
                                                                                                                                                 © Blue Slate Solutions 2010
Redundancy creates fragility



                                     Corporate data



                                                                               Data
                          System B




                                          System C




                                                         System D
      System A




                                                                    System E
                                                                               Applications


                                                                               Technology
                                                                               platforms


                 Corporate networks and infrastructure services




                                                     9
                                                                                © Blue Slate Solutions 2010
Manual workflow


   Document due dates /timeframes




                                                                                                  Summary
                                                                                Withholding     Report Due
                                                       Last Date to Enter-       Date - 15     Date - Due 45       Demand
                                         Initial Due   providers will go on      Calendar         days after      Letter Due
              Quarter End                   Date-           Warning                days       Initial Due Date       Date
                             3/31/2009    4/30/2009                 5/15/2009    5/30/2009         6/14/2009        6/29/2009
                             6/30/2009    7/30/2009                 8/14/2009    8/29/2009         9/13/2009        9/28/2009
                             9/30/2009   10/30/2009                11/14/2009   11/29/2009        12/14/2009       12/29/2009
                            12/31/2009    1/30/2010                 2/16/2010      3/3/2010        3/16/2010        3/31/2010
                             3/31/2010    4/30/2010                 5/16/2010    5/31/2010         6/14/2010        6/29/2010
                             6/30/2010    7/30/2010                 8/15/2010    8/30/2010         9/13/2010        9/28/2010
                             9/30/2010   10/30/2010                11/15/2010   11/30/2010        12/14/2010       12/29/2010
                            12/31/2010    1/30/2011                 2/15/2011      3/2/2011        3/16/2011        3/31/2011




                                                           10
                                                                                                                 © Blue Slate Solutions 2010
Business Methodology




                © Blue Slate Solutions 2010
Business methodology



   Discover and validate strategy



   Ground leadership in possibility



   Conduct cross-functional interviews




                          12
                                         © Blue Slate Solutions 2010
Organizational maturity model: transformational change
                          Level 1                 Level 2              Level 3     Level 4              Level 5
                    Informal/Ad hoc          Formal/Documented        Integrated   Strategic          Optimized

                Individual Success                                                             Enterprise Collaboration
   People       “Fire fighting is a way of                                                     Highly Agile
                life.”                                                                         Strategically focused
                Uncoordinated                                                                  Rewarded on Enterprise
                relationships                                                                  Success
                In competition


 Process and    Ad Hoc                                                                         Adaptive
 Technology     Chaotic                                                                        Opportunistic
                Inconsistent                                                                   Proactive
                                                                                               Agile


Communication   Ad Hoc                                                                         Preventive
                Chaotic                                                                        Highly Adaptive
                No single source of truth                                                      Opportunistic
                                                                                               Community based (All
                                                                                               stakeholders)


 Measurement    Ad Hoc                                                                         Data is used to evaluate
                Manual                                                                         and select process
                People-based                                                                   improvements




   Budget       Ad Hoc                                                                         Opportunistic
                Uncoordinated                                                                  Strategically Focused
                Hidden spend
                Individual Project based




                                                                 13
                                                                                                © Blue Slate Solutions 2010
Business tract findings

Cascading impact
    System count high (2X)

    Homegrown % high (70+%)
         Process standardization low (1:2 average uses/application)

         Process integration low (forced manual tracking/reporting)

    Architectural and talent investments not fully leveraged

Opportunities High for Transformation
         Scalability

         Agility

         Reporting

Bottom Line
    Business needs not being met today or tomorrow



                                                  14
                                                                      © Blue Slate Solutions 2010
aligns transformation




Definition of future state

Iterative roadmap to target
architecture




                              15
                                    © Blue Slate Solutions 2010
building blocks

                                                        Target
                                                        •   Structured EA transformation plan




                                             Industry
                                                        •   Organizational level work processes (all receipt mediums)
                                                        •   Single sources of truth (data integrity)
                                                        •   Organizational Integration / Sourcing
                                                        •   COTS Component Architecture (ECM, BPM, BRE, BI/DW)
                                                        •   STP / Exception Processing / DRY/ Case Management
                                                        •   Program / Change Management /Project Governance



               Leverage                                                                                 Mitigate




                                                                                         Functions
Functions




               • Deep departmental process understanding                                                •   Separation of Work (LOB, Department, etc.)
               • Uncover/Redirect current manual process labor                                          •   Lack of Document Association (Manual)
               • Retain transitional value non-core point solutions                                     •   High Pain/Cost Process Decentralization
                                                                                                        •   Security Breaches, Process/Control Gaps
                                                                                                        •   Document centric workflow, manual data collection

               • Extranet Leadership                                                     Organization   •   Silo-based IT investment, Multitude of systems/apps
Organization




               • Diversified LOBs                                                                       •   Disparate Data
               • Outsourcing Experience                                                                 •   Redundant Data Entry
                                                                                                        •   Architecture Limitations and Cost Implication




                                                                                   16
                                                                                                                                               © Blue Slate Solutions 2010
Operating model: key informer for architecture




                              17
                                                 © Blue Slate Solutions 2010
Target architecture
                                                                                                                              View
  Presentation Tier                                                                                                           Layout
                                               Online Provider
                                WS                Services             iPhone           Android            Facebook           Security


  Application Tier
                              Request                                               ID Notifiier
                                                             NRQT                                                 …           Aggregation
                              Tracking                                                 MAD
                                                                                                                              Business Rules
                                                                                                                              SDO
  Services / Business Tier                                                                                                    Work Flow
                                                         canonical data models                                                Transactions
                                                                                                                              Security

             Security               Logging       Member Data           Provider Data          Claim Data             Other
             Service                Service       Service               Service                Service                Services…


  Integration Tier                                               object domain
                                                                                                                              Data abstraction
                                                                                                                              DAO
                       O-R             O-XML         O-Unstructured             O-API / WS            O-Screen Scrape         Transactions
                                                                                                                              Security
                                                       native/proprietary domain
                                                                 Enterprise System Components
  EIS Tier
                                                                                                                              Persistence
                     Host Systems                                                      Document Mgmt                          Transactions
                                                                                       System
                                                                                                                              Categorization
                     OLTP data
                     sources
                                                                                                                              Indexing
                                                                                       Workflow Engine      Messaging         Security
                     LDAP                OLAP data
                     repositories        sources                                       Rules Engine         ETL




                                                                          18
                                                                                                                                  © Blue Slate Solutions 2010
Unified data speeds integration



   Unique business
                          Medical Review     Claims         Provider
      processes

     Shared data

  Standard canonical
     data formats




                       Common, shared data and canonical data formats




                                     19
                                                                © Blue Slate Solutions 2010
Channels shouldn’t matter




          IVR



          call
         center


         email



         portal
                                 One process, many
                                 channels / contexts
         image




                            20
                                                   © Blue Slate Solutions 2010
Avoid the Big Bang




                          Align
                          Architect
                          Iterate
                          Apply 80/20
                          Measure



                     21
                                        © Blue Slate Solutions 2010
Actionable




             22
                  © Blue Slate Solutions 2010
Maturity and relative IT spending




                             23
                                    © Blue Slate Solutions 2010
The business operates, but how?

                          Classic                           Optimized

                  Mostly human with some static     Automated, flexible, DSL with
      Rules       systems                           human for exceptions


                  Manual, escalation by
                                                    Automated, SLAs, consistent, cross-
    Workflow      complaint, process knowledge
                                                    department
                  by experience within department

                                                    Electronic repository, single location
                  Paper-based, curriers, access
  Documentation   challenges (timeliness, copies)
                                                    for all documents, effective retention
                                                    and security


                  Ad-hoc, broadcast, many pull
  Communication   requests
                                                    Just-in-time, targeted



                  Stove-pipe (department,
                  purpose and technology),          Shared services, integrated data,
    Systems       redundant functionality,          systems of record
                  duplicated or inaccessible data


                                      24
                                                                        © Blue Slate Solutions 2010
Resulting transformational maturity progression
                            Level 1                     Level 2                      Level 3                Level 4                 Level 5
                       Informal/Ad hoc            Formal/Documented                 Integrated             Strategic              Optimized
                  Individual Success           Roles well understood       Program level              Collaborative       Enterprise Collaboration
                  “Fire fighting is a way of   Coordinated Relationships   Coordination               Aligned             Highly Agile
                  life.”                                             2a    Commonality driven2b
                                               Performance Measured                                   Data driven         Strategically focused
    People        Uncoordinated                                            Customer focused
                                               Standardized training                                  Thinkers vs Doers   Rewarded on
                  relationships                                            Rules assume low level                         Enterprise Success
                  In competition                                           tasks
                  Ad Hoc                       Emerging                    Defined                    Aligned             Adaptive
                                                                    1
                  Chaotic                      Standardized                Structured                 Disciplined         Opportunistic
  Process and
                  Inconsistent                 Isolated                    Measured                   Predictable         Proactive
  Technology
                                               Repeatable           7      Competent             6    Quantitatively      Agile
                                                                                                      Measured
                  Ad Hoc                       Common language             Common language            Aligned across      Preventive
                  Chaotic                      emerging            2a      Standards Training         and outside         Highly Adaptive
                  No single source of truth    Gaps understood and         Tied to Performance        Enterprise          Opportunistic
Communication                                  reconciled                  Systemic Quality Checks                        Community based (All
                                               Quality checks
                                                                                              8
                                                                           Shift burden to Supplier                       stakeholders)


                  Ad Hoc                       Standardized         2a     Proactive                  Qualitative         Data is used to evaluate
                  Manual                       Repeatable                  Aligned                    assessment          and select opportunities
Measurement and   People-based                 Emerging proactively        Automated
    Control                                                                                    5
                  Silo                         Emerging Automation         Enterprise
                                               Portfolio
                  Ad Hoc                       Emerging Spend Visibility   Clear Spend Visibility     Aligned             Opportunistic
                  Uncoordinated                Coordinated          2      Program Approach           Predictable         Strategically Focused
                  Hidden spend                 Emerging Control            Controlled                 Agile
    Budget
                  Individual Project based     Coordinated Projects        ROI visibility




                                                                      25
                                                                                                                          © Blue Slate Solutions 2010
Kick-start techniques


  Leadership

  Qualifiers and competes

  High-value data

  Key process standardization

  Commodity technology

  Meaningful POC opportunities


                            26
                                 © Blue Slate Solutions 2010
The value of Blue Slate

  Blue Slate brings…
     External view

     Broad experience

     Focus

  You receive…
     The BluePRINT

  Enabling greater…
     Level of competitiveness

     Leverage of existing systems

     Efficiency and utilization

                                    27
                                         © Blue Slate Solutions 2010
What’s on your mind?




             ?              ?
                       28
                                © Blue Slate Solutions 2010

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Blue Slate Health IT award winning payer case study

  • 1. The Road to Transformation Ensuring your infrastructure will meet business vision today and tomorrow December 7, 2010 © Blue Slate Solutions 2010
  • 2. About Blue Slate Solutions Clientele 4 of the top 20 health payers including 7 BCBS plans 2 of them in the top 3 Experience 100+ healthcare-specific projects 25+ different healthcare entities Liz Gaudet Dave Read, CISSP • Healthcare Leader at Blue Slate • Blue Slate CTO and Chief Solution Architect • 26 years multi-payer experience • 20+ years tech leadership experience • Business process and strategy focus • Strategy and technology focus • Passionate about your success • Passionate about governance and security 2 © Blue Slate Solutions 2010
  • 3. Our client 40 year old US payer, 2500+ employees across multiple locations serving several million subscribers Will current architecture serve future business vision? How can we surpass our competition? 3 © Blue Slate Solutions 2010
  • 4. Two tracks; one destination Current State Applications Grounding Technologies Strategy Organization Business Technology 4 © Blue Slate Solutions 2010
  • 5. Technology Methodology © Blue Slate Solutions 2010
  • 6. Technology methodology Discover IT organization’s alignment and skills Examine technology capacity and flexibility Assess application functionality and data 6 © Blue Slate Solutions 2010
  • 7. Architectural maturity model: transformational change Standardized Business Business Silos Optimized Core Technology Modularity Companywide Plug-and-play Local IT Shared technical IT Capability standardized business process applications platforms process or data modules ROI of local Cost and quality Business Speed to market, business Reduced IT costs of business Objectives strategic agility initiatives operations 7 © Blue Slate Solutions 2010
  • 8. Systems and stovepipes Department 1 – Imaging, Workflow Department 2 – Portal and eServices LOB 1 Inbound Paper MYSE Core Services (data tier) Doc WFE Appeals Inbound Paper – Inbound CORR DDI (current) DDI (rewrite) Claims EDI Inbound Paper– Escalation Inquiry Notification Email INV Tracking Inbound Paper Finance Tracking Tracking System COB Inbound paper – Inbound Corr – ADI-C# Enroll Other Call Center Inquiry FIN Tracking Tracking System System LOB 2 Portal Services Claims - Initial Extract NTI Medical Review Tracking System NT2 LOB 1 Appeals System Claims Processing NT-Agg COB Tracking System secondary NT2A DWH- Informatics EDI Systems Mainframe Systems Call Center Technology ETL Mainframe IVR / VRU EDI Gateway Programming Analytics & Stats Other Corp Tools... 8 © Blue Slate Solutions 2010
  • 9. Redundancy creates fragility Corporate data Data System B System C System D System A System E Applications Technology platforms Corporate networks and infrastructure services 9 © Blue Slate Solutions 2010
  • 10. Manual workflow Document due dates /timeframes Summary Withholding Report Due Last Date to Enter- Date - 15 Date - Due 45 Demand Initial Due providers will go on Calendar days after Letter Due Quarter End Date- Warning days Initial Due Date Date 3/31/2009 4/30/2009 5/15/2009 5/30/2009 6/14/2009 6/29/2009 6/30/2009 7/30/2009 8/14/2009 8/29/2009 9/13/2009 9/28/2009 9/30/2009 10/30/2009 11/14/2009 11/29/2009 12/14/2009 12/29/2009 12/31/2009 1/30/2010 2/16/2010 3/3/2010 3/16/2010 3/31/2010 3/31/2010 4/30/2010 5/16/2010 5/31/2010 6/14/2010 6/29/2010 6/30/2010 7/30/2010 8/15/2010 8/30/2010 9/13/2010 9/28/2010 9/30/2010 10/30/2010 11/15/2010 11/30/2010 12/14/2010 12/29/2010 12/31/2010 1/30/2011 2/15/2011 3/2/2011 3/16/2011 3/31/2011 10 © Blue Slate Solutions 2010
  • 11. Business Methodology © Blue Slate Solutions 2010
  • 12. Business methodology Discover and validate strategy Ground leadership in possibility Conduct cross-functional interviews 12 © Blue Slate Solutions 2010
  • 13. Organizational maturity model: transformational change Level 1 Level 2 Level 3 Level 4 Level 5 Informal/Ad hoc Formal/Documented Integrated Strategic Optimized Individual Success Enterprise Collaboration People “Fire fighting is a way of Highly Agile life.” Strategically focused Uncoordinated Rewarded on Enterprise relationships Success In competition Process and Ad Hoc Adaptive Technology Chaotic Opportunistic Inconsistent Proactive Agile Communication Ad Hoc Preventive Chaotic Highly Adaptive No single source of truth Opportunistic Community based (All stakeholders) Measurement Ad Hoc Data is used to evaluate Manual and select process People-based improvements Budget Ad Hoc Opportunistic Uncoordinated Strategically Focused Hidden spend Individual Project based 13 © Blue Slate Solutions 2010
  • 14. Business tract findings Cascading impact System count high (2X) Homegrown % high (70+%) Process standardization low (1:2 average uses/application) Process integration low (forced manual tracking/reporting) Architectural and talent investments not fully leveraged Opportunities High for Transformation Scalability Agility Reporting Bottom Line Business needs not being met today or tomorrow 14 © Blue Slate Solutions 2010
  • 15. aligns transformation Definition of future state Iterative roadmap to target architecture 15 © Blue Slate Solutions 2010
  • 16. building blocks Target • Structured EA transformation plan Industry • Organizational level work processes (all receipt mediums) • Single sources of truth (data integrity) • Organizational Integration / Sourcing • COTS Component Architecture (ECM, BPM, BRE, BI/DW) • STP / Exception Processing / DRY/ Case Management • Program / Change Management /Project Governance Leverage Mitigate Functions Functions • Deep departmental process understanding • Separation of Work (LOB, Department, etc.) • Uncover/Redirect current manual process labor • Lack of Document Association (Manual) • Retain transitional value non-core point solutions • High Pain/Cost Process Decentralization • Security Breaches, Process/Control Gaps • Document centric workflow, manual data collection • Extranet Leadership Organization • Silo-based IT investment, Multitude of systems/apps Organization • Diversified LOBs • Disparate Data • Outsourcing Experience • Redundant Data Entry • Architecture Limitations and Cost Implication 16 © Blue Slate Solutions 2010
  • 17. Operating model: key informer for architecture 17 © Blue Slate Solutions 2010
  • 18. Target architecture View Presentation Tier Layout Online Provider WS Services iPhone Android Facebook Security Application Tier Request ID Notifiier NRQT … Aggregation Tracking MAD Business Rules SDO Services / Business Tier Work Flow canonical data models Transactions Security Security Logging Member Data Provider Data Claim Data Other Service Service Service Service Service Services… Integration Tier object domain Data abstraction DAO O-R O-XML O-Unstructured O-API / WS O-Screen Scrape Transactions Security native/proprietary domain Enterprise System Components EIS Tier Persistence Host Systems Document Mgmt Transactions System Categorization OLTP data sources Indexing Workflow Engine Messaging Security LDAP OLAP data repositories sources Rules Engine ETL 18 © Blue Slate Solutions 2010
  • 19. Unified data speeds integration Unique business Medical Review Claims Provider processes Shared data Standard canonical data formats Common, shared data and canonical data formats 19 © Blue Slate Solutions 2010
  • 20. Channels shouldn’t matter IVR call center email portal One process, many channels / contexts image 20 © Blue Slate Solutions 2010
  • 21. Avoid the Big Bang Align Architect Iterate Apply 80/20 Measure 21 © Blue Slate Solutions 2010
  • 22. Actionable 22 © Blue Slate Solutions 2010
  • 23. Maturity and relative IT spending 23 © Blue Slate Solutions 2010
  • 24. The business operates, but how? Classic Optimized Mostly human with some static Automated, flexible, DSL with Rules systems human for exceptions Manual, escalation by Automated, SLAs, consistent, cross- Workflow complaint, process knowledge department by experience within department Electronic repository, single location Paper-based, curriers, access Documentation challenges (timeliness, copies) for all documents, effective retention and security Ad-hoc, broadcast, many pull Communication requests Just-in-time, targeted Stove-pipe (department, purpose and technology), Shared services, integrated data, Systems redundant functionality, systems of record duplicated or inaccessible data 24 © Blue Slate Solutions 2010
  • 25. Resulting transformational maturity progression Level 1 Level 2 Level 3 Level 4 Level 5 Informal/Ad hoc Formal/Documented Integrated Strategic Optimized Individual Success Roles well understood Program level Collaborative Enterprise Collaboration “Fire fighting is a way of Coordinated Relationships Coordination Aligned Highly Agile life.” 2a Commonality driven2b Performance Measured Data driven Strategically focused People Uncoordinated Customer focused Standardized training Thinkers vs Doers Rewarded on relationships Rules assume low level Enterprise Success In competition tasks Ad Hoc Emerging Defined Aligned Adaptive 1 Chaotic Standardized Structured Disciplined Opportunistic Process and Inconsistent Isolated Measured Predictable Proactive Technology Repeatable 7 Competent 6 Quantitatively Agile Measured Ad Hoc Common language Common language Aligned across Preventive Chaotic emerging 2a Standards Training and outside Highly Adaptive No single source of truth Gaps understood and Tied to Performance Enterprise Opportunistic Communication reconciled Systemic Quality Checks Community based (All Quality checks 8 Shift burden to Supplier stakeholders) Ad Hoc Standardized 2a Proactive Qualitative Data is used to evaluate Manual Repeatable Aligned assessment and select opportunities Measurement and People-based Emerging proactively Automated Control 5 Silo Emerging Automation Enterprise Portfolio Ad Hoc Emerging Spend Visibility Clear Spend Visibility Aligned Opportunistic Uncoordinated Coordinated 2 Program Approach Predictable Strategically Focused Hidden spend Emerging Control Controlled Agile Budget Individual Project based Coordinated Projects ROI visibility 25 © Blue Slate Solutions 2010
  • 26. Kick-start techniques Leadership Qualifiers and competes High-value data Key process standardization Commodity technology Meaningful POC opportunities 26 © Blue Slate Solutions 2010
  • 27. The value of Blue Slate Blue Slate brings… External view Broad experience Focus You receive… The BluePRINT Enabling greater… Level of competitiveness Leverage of existing systems Efficiency and utilization 27 © Blue Slate Solutions 2010
  • 28. What’s on your mind? ? ? 28 © Blue Slate Solutions 2010