A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
Automated Prior Authorization: A High-Value OpportunityCognizant
In the face of manual PA proliferation and pressure from the value-based care model, the need is growing for real-time electronic PA systems that will ease the administrative burden on stakeholders throughout the healthcare ecosystem.
How Decision-Support Tools Cure the Prior Authorization Time DrainCognizant
A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
The Population Health Management Market 2015Lifelog Health
Population health management is a problem term because it can mean something different to each person who hears it. However, I believe that the words capture the overall spirit and energy of healthcare reform in a unique way. Providers are thinking big when it comes to a patient’s engagement, responsibility, and preventative care, and they’re leveraging technology to do it. I discuss an overall picture of PHM, present some useful technology, and tell a few PHM stories herein.
PYA Principal Carol Carden and Senior Manager Angie Caldwell presented “Hot Topics in Physician Compensation” at the Kentucky Society of CPAs (KY CPA) Health Care Conference, May 18, 2016. The presentation explored the latest developments in physician compensation structure, as well as considerations related to stacking compensation elements, the role and impact of quality incentives, the latest in affiliation models, and population health initiatives.
Mass HIway Enrollment and Onboarding - May 8, 2014MassEHealth
The document provides an overview of the enrollment and onboarding process for connecting to the Massachusetts Health Information Highway (Mass HIway). It discusses the Mass HIway, including its benefits and use cases. It also covers determining the appropriate connection type, including Webmail, LAND device, and Direct connections. Finally, it outlines the participant types and agreements involved in the onboarding process, including the participation agreement and the role of the Access Administrator.
Challenges healthcare faces in making patient data actionable:
A. Automating chart review for quality measures, medical necessity review.
B. Categorizing patient risk for appropriate reimbursement in capitated payment models
C. Enhancing diagnostics, enabling differential diagnosis
D. Discovering correlations with predictive analytics
E. Automating administrative functions, such as scheduling, follow-up care
Care Management Part 2 - A Critical Component of Effective Population HealthHealth Catalyst
Care management plays a central role in the world of value-based reimbursements, at-risk contracts, and population health management. Such programs require high-touch and resource-intensive care as teams work to deliver on the substantial promise of delivering patient care improvements while reducing costs.
Opportunity analysis uses data to identify potential improvement initiatives and quantifies the value of these initiatives—both in terms of patient care benefits and financial impact. This process is an effective way to find unwarranted and costly clinical variation and, in turn, develop strategies to reduce it, improving outcomes and saving costs along the way. Standardizing the opportunity analysis process makes it repeatable and prioritizes actionable opportunities.
Quarterly opportunity analysis should follow four steps:
Kicking off the analysis by getting analysts together to do preliminary analysis and brainstorm.
Engaging with clinicians to identify opportunities and, in the process, get clinician buy in.
Digging deeper into the suggested opportunities to prioritize those that offer the greatest benefits.
Presenting findings to the decision makers.
Automated Prior Authorization: A High-Value OpportunityCognizant
In the face of manual PA proliferation and pressure from the value-based care model, the need is growing for real-time electronic PA systems that will ease the administrative burden on stakeholders throughout the healthcare ecosystem.
How Decision-Support Tools Cure the Prior Authorization Time DrainCognizant
A collaboration between Cognizant, the New England Healthcare Exchange Network and Informatics In Context is demonstrating how a real-time prior authorization (PA) system for medical and administrative processes saves time and money.
The Population Health Management Market 2015Lifelog Health
Population health management is a problem term because it can mean something different to each person who hears it. However, I believe that the words capture the overall spirit and energy of healthcare reform in a unique way. Providers are thinking big when it comes to a patient’s engagement, responsibility, and preventative care, and they’re leveraging technology to do it. I discuss an overall picture of PHM, present some useful technology, and tell a few PHM stories herein.
PYA Principal Carol Carden and Senior Manager Angie Caldwell presented “Hot Topics in Physician Compensation” at the Kentucky Society of CPAs (KY CPA) Health Care Conference, May 18, 2016. The presentation explored the latest developments in physician compensation structure, as well as considerations related to stacking compensation elements, the role and impact of quality incentives, the latest in affiliation models, and population health initiatives.
Mass HIway Enrollment and Onboarding - May 8, 2014MassEHealth
The document provides an overview of the enrollment and onboarding process for connecting to the Massachusetts Health Information Highway (Mass HIway). It discusses the Mass HIway, including its benefits and use cases. It also covers determining the appropriate connection type, including Webmail, LAND device, and Direct connections. Finally, it outlines the participant types and agreements involved in the onboarding process, including the participation agreement and the role of the Access Administrator.
Challenges healthcare faces in making patient data actionable:
A. Automating chart review for quality measures, medical necessity review.
B. Categorizing patient risk for appropriate reimbursement in capitated payment models
C. Enhancing diagnostics, enabling differential diagnosis
D. Discovering correlations with predictive analytics
E. Automating administrative functions, such as scheduling, follow-up care
Care Management Part 2 - A Critical Component of Effective Population HealthHealth Catalyst
Care management plays a central role in the world of value-based reimbursements, at-risk contracts, and population health management. Such programs require high-touch and resource-intensive care as teams work to deliver on the substantial promise of delivering patient care improvements while reducing costs.
Opportunity analysis uses data to identify potential improvement initiatives and quantifies the value of these initiatives—both in terms of patient care benefits and financial impact. This process is an effective way to find unwarranted and costly clinical variation and, in turn, develop strategies to reduce it, improving outcomes and saving costs along the way. Standardizing the opportunity analysis process makes it repeatable and prioritizes actionable opportunities.
Quarterly opportunity analysis should follow four steps:
Kicking off the analysis by getting analysts together to do preliminary analysis and brainstorm.
Engaging with clinicians to identify opportunities and, in the process, get clinician buy in.
Digging deeper into the suggested opportunities to prioritize those that offer the greatest benefits.
Presenting findings to the decision makers.
ExecutiveInsight July 2014 - Supply Chain cover storygaryjohnson500
The document discusses strategies for optimizing healthcare supply chain management. It notes that simply relying on group purchasing organizations for lower prices is no longer sufficient, and health systems are now looking more closely at cost variability, utilization, and quality across hospitals, units, and clinicians. Advanced analytics and improved value analysis processes are helping to generate savings. However, fully optimizing supply chain management requires accountability across the entire health system to improve processes and focus on patient outcomes. Automating supply chain processes can also reduce waste compared to current manual methods. Coordinating all facets of vendor management through a streamlined supply chain is key to generating savings from this area, which accounts for up to half of total healthcare costs.
Virtual health is supporting continuing efforts to further humanize health care by extending and expanding the concept of a patient-centric care delivery model into one that is truly life-centric.
Virtual health uses telecommunication and networked technologies to connect clinicians with patients (and with other clinicians) to remotely deliver health care services and support well-being. For providers, committing to virtual health at a personal and organizational level affords ever-increasing opportunities to deliver the right care at the right time in the right place, in a connected and coordinated manner.
By strengthening and facilitating a therapeutic alliance between clinicians and patients, virtual health is an important step on our continuous journey to humanize health care. It works within and around a patient’s life, as opposed to their sickness, to deliver care when, where, and how they need and want it. Also, virtual health works its way into consumers’ daily routines by being embedded in electronic devices associated with living life (e.g., smartphones and personal computers) more so than caring for sickness.
The healthcare industry is primed for expanded adoption of virtual health; a 2016 report estimated that the US virtual health market will reach $3.5 billion in revenues by 2022. Several factors are elevating stakeholder interest, including expected physician shortages, continued growth in digital technologies, changing reimbursement models, increasing consumer demand, and the evolving regulatory landscape. One game-changer: Today, nine in 10 American adults use the internet, giving clinicians the capability and flexibility to communicate with and serve health care consumers via the web.
Three Strategies to Deliver Patient-Centered Care in the Next NormalHealth Catalyst
Juggling financial demands, uncertain healthcare legislation, and COVID-19 can distract healthcare leaders from the most important aspect of care—patients. Delivering patient-centered care in this volatile market can be challenging, especially when traditional healthcare methods (e.g., in-person visits) are on hold. These sudden disruptions to routine care have highlighted the importance of keeping patients at the center of care, whether care delivery is in-person or virtual. Health systems can manage competing priorities, adjust to pandemic-induced changes, and deliver patient-centered care by focusing on three strategies:
Improve the patient experience.
Implement the Meaningful Measures Initiative.
Transition in-person visits to virtual.
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
Platforms and Partnerships: The Building Blocks for Digital InnovationHealth Catalyst
Virtually all service-oriented industries have experienced massive disruption and transformation, resulting from the confluence of digital, mobile, cloud, data, and consumerization. And then there’s healthcare…
In this webinar Ryan Smith, executive advisor at Health Catalyst, shares practical insights gained from his combined 25 years of IT and digital leadership roles at Banner Health and Intermountain Healthcare. He explores why our industry is struggling to provide the tools and self-service experiences that patients and consumers have come to expect in every other aspect of their lives. To attract and retain patients and members, healthcare organizations need to “shift gears” and go on the digital offensive to sustain brand loyalty; however, decades of siloed, monolithic approaches to implementing technology and managing data continue to hamper industry progress.
During this session, Ryan shares his approach for building business support to enable digital transformation.
By viewing this webinar, you will learn key digitization concepts:
- How to conceptualize a digital enablement framework.
- Ten strategic guiding principles for technology leaders.
- Why it’s vital to create business-driven technology governance.
- Why building strategic vendor partnerships really matters.
- How to apply case studies to bolster digital investments.
PYA Principal Martie Ross joined University of Kansas Medical Center’s Robert Moser, MD, and CIO Chris Hansen for the keynote presentation at the joint symposium by Heart of America Healthcare Information and Management Systems Society and Missouri Health Information Management Association, September 14, 2016, at Johnson County Community College in Overland Park, Kansas. They discussed insights related to the role of advanced analytics and technology in transforming and transitioning to new payment models.
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
CFO Strategies for Balancing Fee-for-Service and ValuePhytel
Moving from fee-for-service to value-based care is not easy. However, leading health systems are all following a similar blueprint that enables the move to value-based care.
Download this whitepaper to learn how:
- Bon Secours Richmond - Closed 75,801 gaps in care within 12 months, generating $7 million in revenue for chronic & preventive care, while improving quality.
- Northeast Georgia Medical Center - Decreased HbA1C levels across uncontrolled diabetes by an average of 1.6 points within 120 days.
- Riverside Medical Center - Reduced unnecessary readmissions by 40% by using automation to reach and assess patients post discharge.
- Prevea Health - Increased care management productivity by 150% by automatically identifying high risk patients, and automating patient engagement.
A look at strategies for lowering hospital readmissions across the continuum of care.
Hospital readmissions are a multi-dimensional problem. No single player or entity is entirely responsible for reducing excess readmissions. By improving our understanding of each touch point along the patient care continuum, strategies can be developed that ultimately reduce total readmissions.
This paper explores the roles of patients and providers in reducing readmissions and reviews several strategies that each can implement to help reduce readmission rates.
-Which patients are at high risk of hospital readmission?
-Comprehensive discharge planning strategies
-The physician’s role in lowering hospital readmission rates
-Optimizing communications handoffs between providers
-Building patient-centered transitional care models
-End of life planning
Why Clinical Quality Should Be Your Core Business StrategyHealth Catalyst
Over 100 years ago, healing professionals and healthcare itself went through a massive transformation that led us to the models of care delivery that we use today. Dr. Brent James argues that we are now, again, at a once-in-a-century inflection point to change the course of healthcare. Change takes real effort, but provides massive opportunity.
Those changes include a move away from the highly-profitable fee-for-service payment to fee-for-value. An IOM report, published in 2010, substantiated that more than a third of healthcare spending is waste. Pay-for-value aligns financial returns for those who invest in waste elimination. It also requires that clinicians move away from the craft of medicine to the science of medicine, using data and evidence to drive better clinical care.
As the vice president and chief quality officer at Intermountain Healthcare, Dr. James led much of the change that produced Intermountain’s recognized operational and clinical excellence. In this webinar Dr. James educates and inspires all of us to do great work by sharing practical stories of how data has become the critical tool to help healthcare shift from revenue enhancement to clinical quality, which produces the most affordable care.
Learn how to:
- Use data to find variations in both cost and quality of care.
- Standardize care without demotivating underperforming outliers.
- Build a culture of data-driven care providers.
- Develop an improvement strategy that you can start today.
Sought the world over, Dr. James is a recognized expert in this outcomes improvements area. He has championed the standardization of clinical care through data collection and analysis on a wide variety of treatment protocols and complex care processes for more than 20 years.
Presentation Zeroes in on Successful CIN PYA, P.C.
A 335-bed hospital in Florida sought to form a clinically integrated network (CIN) with its physicians to address strategic challenges. It formed a Clinical Integration Committee of physician leaders and gave them 9 months to gain commitment. The Committee educated physicians and formed workgroups to define the CIN. This led to physician summits that built consensus on a governance structure. A Physician Hospital Organization was then formally established with equal physician and hospital representation to govern the CIN within 9 months as planned.
Six Steps to Managing an Infection Control BreachHealth Catalyst
Despite widespread efforts to improve patient safety, infection control breaches still happen at an alarming rate. In order to improve patient safety and prevent infections, healthcare organizations need to have infection control procedures in place and regularly assess protocols and adherence to these policies. In the case of an infection control breach, organizations need to be prepared to act quickly and follow a six-step evaluation procedure outlined by the CDC:
1. Identify the infection control breach.
2. Gather additional data.
3. Notify and involve key stakeholders.
4. Perform a qualitative assessment.
5. Make decisions about patient notification and testing.
6. Handle communications and logistical issues.
White Paper - eCQMs: It's Time to Make Data Quality the No. 1 Priority Q-Centrix
This white paper will examine eCQM data quality issues and their implications. It will raise questions hospitals should consider when developing strategies to improve their eCQM capabilities. Lastly, it will outline how they can benefit from implementing better data quality control practices and present new developments in eCQM data collection and reporting.
How to Run Your Healthcare Analytics Operation Like a BusinessHealth Catalyst
A robust data analytics operation is necessary for healthcare systems’ survival. Just like any business, the analytics enterprise needs to be well managed using the principles of successful business operations.
This article walks through how to run an analytics operation like a business using the following five-question framework:
Who does the analytics team serve and what are those customers trying to do?
What services does the analytics team provide to help customers accomplish their goals?
How does the analytics team know they’re doing a great job and how do they communicate that effectively to the leadership team?
What is the most efficient way to provide analytics services?
What is the most effective way to organize?
How to Design an Effective Clinical Measurement System (And Avoid Common Pitf...Health Catalyst
The document discusses how to design an effective clinical measurement system. It explains that there are two aims for clinical measurement: measurement for selection or measurement for improvement. Measurement for selection focuses on comparative rankings which can lead to gaming of the system, while measurement for improvement focuses on processes and aims to make improvements. The key aspects of an effective system are tracking the right data elements embedded in clinical workflows, using structured expert opinion to identify data, and including mechanisms to validate the measurement system and provide feedback.
Quality and Outcome Framework (QOF) is a voluntary annual incentive programme for GPs in England, detailing practice achievement results. The primary objective of QOF is to drive the quality of primary care and reduce variations in the quality of care amongst GPs
Should healthcare be more digitized? Absolutely. But if we go about it the wrong way... or the naïve way... we will take two steps forward and three steps back.
In this 90-minute webinar, Dale Sanders, President of Technology at Health Catalyst describes the right way to go about the technical digitization of healthcare so that it increases the sense of humanity during the journey.
The topics Dale covers include:
• The human, empathetic components of healthcare’s digitization strategy
• The AI-enabled healthcare encounter in the near future
• Why the current digital approach to patient engagement will never be effective
• The dramatic near-term potential of bio-integrated sensors
• Role of the “digitician” and patient data profiles
• The technology and architecture of a modern digital platform
• The role of AI vs. the role of traditional data analysis in healthcare
• Reasons that home grown digital platforms will not scale, economically
Most of the data that’s generated in healthcare is about administrative overhead of healthcare, not about the current state of patients’ well-being. On average, healthcare collects data about patients three times per year from which providers are expected to optimize diagnoses, treatments, predict health risks and cultivate long-term care plans. Where’s the data about patients’ health from the other 362 days per year?
McKinsey ranks industries based on their Digital Quotient (DQ), which is derived from a cross product of three areas: Data Assets x Data Skills x Data Utilization. Healthcare ranks lower than all industries except mining. It’s time for healthcare to raise its digital quotient, however, it’s a delicate balance. The current “data-driven” strategy in healthcare is a train wreck, sucking the life out of clinicians’ sense of mastery, autonomy, and purpose.
Healthcare’s digital strategy has largely ignored the digitization of patients’ state of health, but that’s changing, and the change will be revolutionary. Driven by bio-integrated sensors and affordable genomics, in the next five years, many patients will possess more data and AI-driven insights about their diagnosis and treatment options than healthcare systems, turning the existing dialogue with care providers on its head. It’s going to happen. Let’s make it happen the right way.
AAMI_HITECH MU: Impact on the Future of HC ITAmy Stowers
Relate the components of The HITECH Act and Meaningful Use to health management technology
Identify whether existing systems meet requirements
Communicate technology needs and request feedback from end users for a smooth transition
Implement best practices to move people and systems forward under these new requirements
The Top Seven Healthcare Outcome Measures and Three Measurement EssentialsHealth Catalyst
Healthcare outcomes improvement can’t happen without effective outcomes measurement. Given the healthcare industry’s administrative and regulatory complexities, and the fact that health systems measure and report on hundreds of outcomes annually, this article adds much-needed clarity by reviewing the top seven outcome measures, including definitions, important nuances, and real-life examples. The top seven categories of outcome measures are:
Mortality
Readmissions
Safety of care
Effectiveness of care
Patient experience
Timeliness of care
Efficient use of medical imaging
CMS used these seven outcome measures to calculate overall hospital quality and arrive at its 2018 hospital star ratings. This article also reiterates the importance of outcomes measurement, clarifies how outcome measures are defined and prioritized, and recommends three essentials for successful outcomes measurement.
Recent reports indicate that physicians are stressed and overburdened by several administrative challenges, leaving them with less time for patient care.
Quality reporting's toll on physician practices in time and money by Dr.Mahbo...Healthcare consultant
The failure in quality improvement is that health IT applications have not been designed to simplify the complexity of value-based contracts into automated and easy-to-use workflows for physicians and care managers. The administrative burden of quality improvement should never fall on physicians and other care providers.This exact problem is why I founded Able Health, which is focused on building software that simplifies quality reporting and improvement for all stakeholders. I have written about the need to meet the needs of clinical users in quality improvement through the use of 'design thinking' methods:
ExecutiveInsight July 2014 - Supply Chain cover storygaryjohnson500
The document discusses strategies for optimizing healthcare supply chain management. It notes that simply relying on group purchasing organizations for lower prices is no longer sufficient, and health systems are now looking more closely at cost variability, utilization, and quality across hospitals, units, and clinicians. Advanced analytics and improved value analysis processes are helping to generate savings. However, fully optimizing supply chain management requires accountability across the entire health system to improve processes and focus on patient outcomes. Automating supply chain processes can also reduce waste compared to current manual methods. Coordinating all facets of vendor management through a streamlined supply chain is key to generating savings from this area, which accounts for up to half of total healthcare costs.
Virtual health is supporting continuing efforts to further humanize health care by extending and expanding the concept of a patient-centric care delivery model into one that is truly life-centric.
Virtual health uses telecommunication and networked technologies to connect clinicians with patients (and with other clinicians) to remotely deliver health care services and support well-being. For providers, committing to virtual health at a personal and organizational level affords ever-increasing opportunities to deliver the right care at the right time in the right place, in a connected and coordinated manner.
By strengthening and facilitating a therapeutic alliance between clinicians and patients, virtual health is an important step on our continuous journey to humanize health care. It works within and around a patient’s life, as opposed to their sickness, to deliver care when, where, and how they need and want it. Also, virtual health works its way into consumers’ daily routines by being embedded in electronic devices associated with living life (e.g., smartphones and personal computers) more so than caring for sickness.
The healthcare industry is primed for expanded adoption of virtual health; a 2016 report estimated that the US virtual health market will reach $3.5 billion in revenues by 2022. Several factors are elevating stakeholder interest, including expected physician shortages, continued growth in digital technologies, changing reimbursement models, increasing consumer demand, and the evolving regulatory landscape. One game-changer: Today, nine in 10 American adults use the internet, giving clinicians the capability and flexibility to communicate with and serve health care consumers via the web.
Three Strategies to Deliver Patient-Centered Care in the Next NormalHealth Catalyst
Juggling financial demands, uncertain healthcare legislation, and COVID-19 can distract healthcare leaders from the most important aspect of care—patients. Delivering patient-centered care in this volatile market can be challenging, especially when traditional healthcare methods (e.g., in-person visits) are on hold. These sudden disruptions to routine care have highlighted the importance of keeping patients at the center of care, whether care delivery is in-person or virtual. Health systems can manage competing priorities, adjust to pandemic-induced changes, and deliver patient-centered care by focusing on three strategies:
Improve the patient experience.
Implement the Meaningful Measures Initiative.
Transition in-person visits to virtual.
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
Platforms and Partnerships: The Building Blocks for Digital InnovationHealth Catalyst
Virtually all service-oriented industries have experienced massive disruption and transformation, resulting from the confluence of digital, mobile, cloud, data, and consumerization. And then there’s healthcare…
In this webinar Ryan Smith, executive advisor at Health Catalyst, shares practical insights gained from his combined 25 years of IT and digital leadership roles at Banner Health and Intermountain Healthcare. He explores why our industry is struggling to provide the tools and self-service experiences that patients and consumers have come to expect in every other aspect of their lives. To attract and retain patients and members, healthcare organizations need to “shift gears” and go on the digital offensive to sustain brand loyalty; however, decades of siloed, monolithic approaches to implementing technology and managing data continue to hamper industry progress.
During this session, Ryan shares his approach for building business support to enable digital transformation.
By viewing this webinar, you will learn key digitization concepts:
- How to conceptualize a digital enablement framework.
- Ten strategic guiding principles for technology leaders.
- Why it’s vital to create business-driven technology governance.
- Why building strategic vendor partnerships really matters.
- How to apply case studies to bolster digital investments.
PYA Principal Martie Ross joined University of Kansas Medical Center’s Robert Moser, MD, and CIO Chris Hansen for the keynote presentation at the joint symposium by Heart of America Healthcare Information and Management Systems Society and Missouri Health Information Management Association, September 14, 2016, at Johnson County Community College in Overland Park, Kansas. They discussed insights related to the role of advanced analytics and technology in transforming and transitioning to new payment models.
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
CFO Strategies for Balancing Fee-for-Service and ValuePhytel
Moving from fee-for-service to value-based care is not easy. However, leading health systems are all following a similar blueprint that enables the move to value-based care.
Download this whitepaper to learn how:
- Bon Secours Richmond - Closed 75,801 gaps in care within 12 months, generating $7 million in revenue for chronic & preventive care, while improving quality.
- Northeast Georgia Medical Center - Decreased HbA1C levels across uncontrolled diabetes by an average of 1.6 points within 120 days.
- Riverside Medical Center - Reduced unnecessary readmissions by 40% by using automation to reach and assess patients post discharge.
- Prevea Health - Increased care management productivity by 150% by automatically identifying high risk patients, and automating patient engagement.
A look at strategies for lowering hospital readmissions across the continuum of care.
Hospital readmissions are a multi-dimensional problem. No single player or entity is entirely responsible for reducing excess readmissions. By improving our understanding of each touch point along the patient care continuum, strategies can be developed that ultimately reduce total readmissions.
This paper explores the roles of patients and providers in reducing readmissions and reviews several strategies that each can implement to help reduce readmission rates.
-Which patients are at high risk of hospital readmission?
-Comprehensive discharge planning strategies
-The physician’s role in lowering hospital readmission rates
-Optimizing communications handoffs between providers
-Building patient-centered transitional care models
-End of life planning
Why Clinical Quality Should Be Your Core Business StrategyHealth Catalyst
Over 100 years ago, healing professionals and healthcare itself went through a massive transformation that led us to the models of care delivery that we use today. Dr. Brent James argues that we are now, again, at a once-in-a-century inflection point to change the course of healthcare. Change takes real effort, but provides massive opportunity.
Those changes include a move away from the highly-profitable fee-for-service payment to fee-for-value. An IOM report, published in 2010, substantiated that more than a third of healthcare spending is waste. Pay-for-value aligns financial returns for those who invest in waste elimination. It also requires that clinicians move away from the craft of medicine to the science of medicine, using data and evidence to drive better clinical care.
As the vice president and chief quality officer at Intermountain Healthcare, Dr. James led much of the change that produced Intermountain’s recognized operational and clinical excellence. In this webinar Dr. James educates and inspires all of us to do great work by sharing practical stories of how data has become the critical tool to help healthcare shift from revenue enhancement to clinical quality, which produces the most affordable care.
Learn how to:
- Use data to find variations in both cost and quality of care.
- Standardize care without demotivating underperforming outliers.
- Build a culture of data-driven care providers.
- Develop an improvement strategy that you can start today.
Sought the world over, Dr. James is a recognized expert in this outcomes improvements area. He has championed the standardization of clinical care through data collection and analysis on a wide variety of treatment protocols and complex care processes for more than 20 years.
Presentation Zeroes in on Successful CIN PYA, P.C.
A 335-bed hospital in Florida sought to form a clinically integrated network (CIN) with its physicians to address strategic challenges. It formed a Clinical Integration Committee of physician leaders and gave them 9 months to gain commitment. The Committee educated physicians and formed workgroups to define the CIN. This led to physician summits that built consensus on a governance structure. A Physician Hospital Organization was then formally established with equal physician and hospital representation to govern the CIN within 9 months as planned.
Six Steps to Managing an Infection Control BreachHealth Catalyst
Despite widespread efforts to improve patient safety, infection control breaches still happen at an alarming rate. In order to improve patient safety and prevent infections, healthcare organizations need to have infection control procedures in place and regularly assess protocols and adherence to these policies. In the case of an infection control breach, organizations need to be prepared to act quickly and follow a six-step evaluation procedure outlined by the CDC:
1. Identify the infection control breach.
2. Gather additional data.
3. Notify and involve key stakeholders.
4. Perform a qualitative assessment.
5. Make decisions about patient notification and testing.
6. Handle communications and logistical issues.
White Paper - eCQMs: It's Time to Make Data Quality the No. 1 Priority Q-Centrix
This white paper will examine eCQM data quality issues and their implications. It will raise questions hospitals should consider when developing strategies to improve their eCQM capabilities. Lastly, it will outline how they can benefit from implementing better data quality control practices and present new developments in eCQM data collection and reporting.
How to Run Your Healthcare Analytics Operation Like a BusinessHealth Catalyst
A robust data analytics operation is necessary for healthcare systems’ survival. Just like any business, the analytics enterprise needs to be well managed using the principles of successful business operations.
This article walks through how to run an analytics operation like a business using the following five-question framework:
Who does the analytics team serve and what are those customers trying to do?
What services does the analytics team provide to help customers accomplish their goals?
How does the analytics team know they’re doing a great job and how do they communicate that effectively to the leadership team?
What is the most efficient way to provide analytics services?
What is the most effective way to organize?
How to Design an Effective Clinical Measurement System (And Avoid Common Pitf...Health Catalyst
The document discusses how to design an effective clinical measurement system. It explains that there are two aims for clinical measurement: measurement for selection or measurement for improvement. Measurement for selection focuses on comparative rankings which can lead to gaming of the system, while measurement for improvement focuses on processes and aims to make improvements. The key aspects of an effective system are tracking the right data elements embedded in clinical workflows, using structured expert opinion to identify data, and including mechanisms to validate the measurement system and provide feedback.
Quality and Outcome Framework (QOF) is a voluntary annual incentive programme for GPs in England, detailing practice achievement results. The primary objective of QOF is to drive the quality of primary care and reduce variations in the quality of care amongst GPs
Should healthcare be more digitized? Absolutely. But if we go about it the wrong way... or the naïve way... we will take two steps forward and three steps back.
In this 90-minute webinar, Dale Sanders, President of Technology at Health Catalyst describes the right way to go about the technical digitization of healthcare so that it increases the sense of humanity during the journey.
The topics Dale covers include:
• The human, empathetic components of healthcare’s digitization strategy
• The AI-enabled healthcare encounter in the near future
• Why the current digital approach to patient engagement will never be effective
• The dramatic near-term potential of bio-integrated sensors
• Role of the “digitician” and patient data profiles
• The technology and architecture of a modern digital platform
• The role of AI vs. the role of traditional data analysis in healthcare
• Reasons that home grown digital platforms will not scale, economically
Most of the data that’s generated in healthcare is about administrative overhead of healthcare, not about the current state of patients’ well-being. On average, healthcare collects data about patients three times per year from which providers are expected to optimize diagnoses, treatments, predict health risks and cultivate long-term care plans. Where’s the data about patients’ health from the other 362 days per year?
McKinsey ranks industries based on their Digital Quotient (DQ), which is derived from a cross product of three areas: Data Assets x Data Skills x Data Utilization. Healthcare ranks lower than all industries except mining. It’s time for healthcare to raise its digital quotient, however, it’s a delicate balance. The current “data-driven” strategy in healthcare is a train wreck, sucking the life out of clinicians’ sense of mastery, autonomy, and purpose.
Healthcare’s digital strategy has largely ignored the digitization of patients’ state of health, but that’s changing, and the change will be revolutionary. Driven by bio-integrated sensors and affordable genomics, in the next five years, many patients will possess more data and AI-driven insights about their diagnosis and treatment options than healthcare systems, turning the existing dialogue with care providers on its head. It’s going to happen. Let’s make it happen the right way.
AAMI_HITECH MU: Impact on the Future of HC ITAmy Stowers
Relate the components of The HITECH Act and Meaningful Use to health management technology
Identify whether existing systems meet requirements
Communicate technology needs and request feedback from end users for a smooth transition
Implement best practices to move people and systems forward under these new requirements
The Top Seven Healthcare Outcome Measures and Three Measurement EssentialsHealth Catalyst
Healthcare outcomes improvement can’t happen without effective outcomes measurement. Given the healthcare industry’s administrative and regulatory complexities, and the fact that health systems measure and report on hundreds of outcomes annually, this article adds much-needed clarity by reviewing the top seven outcome measures, including definitions, important nuances, and real-life examples. The top seven categories of outcome measures are:
Mortality
Readmissions
Safety of care
Effectiveness of care
Patient experience
Timeliness of care
Efficient use of medical imaging
CMS used these seven outcome measures to calculate overall hospital quality and arrive at its 2018 hospital star ratings. This article also reiterates the importance of outcomes measurement, clarifies how outcome measures are defined and prioritized, and recommends three essentials for successful outcomes measurement.
Recent reports indicate that physicians are stressed and overburdened by several administrative challenges, leaving them with less time for patient care.
Quality reporting's toll on physician practices in time and money by Dr.Mahbo...Healthcare consultant
The failure in quality improvement is that health IT applications have not been designed to simplify the complexity of value-based contracts into automated and easy-to-use workflows for physicians and care managers. The administrative burden of quality improvement should never fall on physicians and other care providers.This exact problem is why I founded Able Health, which is focused on building software that simplifies quality reporting and improvement for all stakeholders. I have written about the need to meet the needs of clinical users in quality improvement through the use of 'design thinking' methods:
This document discusses how robotic process automation (RPA) can help address challenges in the healthcare sector. It describes how RPA can streamline processes like insurance approval, patient registration, and claims management by gathering data from multiple disparate systems. Implementing RPA can free up healthcare providers and payers to spend more time on high-value work while improving accuracy and reducing costs. The document also outlines some of the manual, repetitive tasks performed by providers and payers that are good candidates for initial RPA automation pilots.
Painsolver is a clinical decision support tool designed to improve healthcare outcomes for low back pain. It addresses limitations in how patient care is currently managed by providing evidence-based guidance, integrating recommendations into workflows, and promoting shared decision making between providers and patients. The tool aims to help organizations and providers succeed under emerging pay-for-performance models by enhancing outcomes and reducing costs over a patient's lifetime. Vertelogics believes Painsolver can help providers and organizations not just survive but thrive as the healthcare system shifts its focus to outcomes-based reimbursement.
This document discusses the use of business process management (BPM) and decision management in the healthcare and life sciences industries. It begins by outlining several challenges facing these industries, including increasing costs, inconsistent quality, and lack of access to care. It then provides examples of how BPM can help address issues like provider process management, payer claims management, and pharmaceutical compliance. The document argues that BPM allows for more efficient, standardized processes that improve outcomes while reducing costs. It also provides an overview of how IBM's BPM solutions approach can help organizations implement these tools.
This document provides a predictive sales report for a retail store. It includes historical unemployment rate data from 1948-1979 which the retail store uses to predict consumer spending and inventory needs. The report finds that increases in the unemployment rate generally cause decreases in consumer spending at the retail store. It recommends the store use the unemployment data and historical trends to estimate future sales and maintain cost-effectiveness.
Healthcare by Any Other Name - Centricity Business WhitepaperGE Healthcare - IT
This document discusses new models of healthcare delivery such as accountable care organizations and integrated health organizations that aim to improve outcomes and reduce costs through greater coordination and integration of care. It summarizes that these models seek to address long-standing issues with the traditional fragmented healthcare system such as its focus on episodic treatment rather than prevention. Critical to enabling these new models is developing an information technology infrastructure that includes electronic medical records, revenue cycle management systems, clinical decision support, and health information exchange capabilities to facilitate data sharing and population health management.
The below stated are the Challenges and business requirements faced .pdfapleather
The below stated are the Challenges and business requirements faced by the hospital
Population health
Population health was one of the biggest ideas in healthcare this past year, and it will likely
maintain or gain momentum in the next few years to come. But despite the frequent use of the
term in the healthcare bubble, population health is a multidisciplinary concept to be shared
between public health agencies, social institutions and policymakers.
Hospitals fit in there somewhere. Defining that role is one of the ongoing challenges they will
face in 2015.
Hospitals\' demand for population health expertise overwhelms the supply. Nearly 60 percent of
health system and hospital CEOs ranked population health as the hardest skill set to find within
the broader healthcare field, according to a 2014 American Hospital Association survey. Further,
nearly half of executives polled identified community and population health management as a
talent gap within their organizations. Some health systems are filling this gap by creating new C-
suite positions: 10 percent of executives indicated their health system had a chief population
health manager.
Quantifying population health is another challenge. Although healthcare leaders need to think
creatively about how to improve the health of a geographic population, they should also maintain
a healthy sense of skepticism about population health efforts. What might seem like a much-
needed intervention on paper, such as a grocery store in a food desert, may be one small piece of
a multipronged solution. There are no silver bullets, after all. Amid excitement for population
health, systems may oversimplify problems and overinvest in solutions only to see the same
health outcomes.
To find success, hospital leaders may need to diminish their traditional reliance on \"programs\"
and instead focus more on partnerships with community organizations and nonprofits. Some
health systems still act as autonomously as they can, ignoring a wealth of expertise and
resources.
\"When we talk to other population health managers, they have unearthed a number of unique
challenges inside their populations, such as domestic violence, elder abuse and other public
health crises,\" says Jason Dinger, PhD, CEO of MissionPoint Health Partners in Nashville, the
accountable care organization affiliated with Saint Thomas Health. \"Unfortunately, most
respond by trying to implement their own unique program to respond to the issue. We usually
encourage them to first speak with the experts in their community who work on these issues
every day. In many cases these are nonprofit organizations that can add great value to the
population health effort but often have trouble engaging and integrating with a health system\'s
efforts.\"
Shifting from volume- to value-based reimbursement
The move from volume- to value-based reimbursement is inevitable. For now, it\'s a matter of
how quickly providers should make it.
Move too fast, and hospitals risk los.
A large Texas hospital implemented GOJO Industries' SMARTLINK Hand Hygiene Solutions, which uses electronic compliance monitoring and on-site clinician support. This led to a 92% increase in hand hygiene compliance rates within 12 weeks on a medical unit. The SMARTLINK system automatically records thousands of hand hygiene events per month, providing more accurate data than traditional observation methods. The success was attributed to both the compliance monitoring data and the on-site support provided to staff.
Understanding clinical data exchange and cda (hl7 201)Edifecs Inc
On top of simple needs for doctors to be connected and be able to efficiently exchange information, there is a lot of external factors driving standardization of information exchange from market to various government initiatives and as the industry moves toward a population health model, there is more need for wider applicability of standards. This Slide share covers an introduction to CDA and establishes the importance of clinical documentation for claims and prior authorization attachments
Chapter 4 Information Systems to Support Population Health Managem.docxketurahhazelhurst
Chapter 4 Information Systems to Support Population Health Management Learning Objectives To be able to understand the data and information needs of health systems in managing population health effectively under value-based payment models. To be able to discuss key health IT tools and strategies for population health management including EHRs, registries, risk stratification, patient engagement, and outreach, care coordination and management, analytics, health information exchange, and telemedicine and telehealth. To be able to discuss the application and use of data analytics to monitor, predict, and improve performance. The enactment of the Affordable Care Act (ACA) brought about sweeping legislation intended to reduce the numbers of uninsured and make health care accessible to all Americans. It also ushered in an era in which changing reimbursement and care delivery models are driving providers from the current fragmented system focused on volume-based services to an outcomes orientation. As a result, the health care system now taking shape is one in which value-based payment models financially reward patient-centered, coordinated, accountable care. Against this backdrop, providers' increasing use of evidence-based medicine and growing capabilities in managing volumes of clinical evidence through sophisticated health IT systems will mean that treatments can be tailored for the individual and interventions can be made earlier to keep patients well. Furthermore, patient engagement is fast becoming a critical component in the care process, particularly in the area of population health management (PHM). Health care providers' interest in improving population health appears to be increasing because of the sudden ubiquity of the phrase, because many are participating in accountable care organizations (ACOs), and because even hospitals not participating in an ACO increasingly have incentives to reduce their number of potentially unavoidable admissions, readmissions, and emergency department visits (Casalino, Erb, Joshi, & Shortell, 2015). In this chapter we'll not only seek a common understanding of PHM but also explore how the advent of shared accountability financial arrangements between providers and purchasers of care has created significant focus on PHM. We'll also review the core processes associated with accountable care and examine the strategic IT investments and data management capabilities required to support population health management and enable a successful transition from volume-based to value-based care. PHM: Key to Success Although the ACO model is still new and evolving, approximately 750 ACOs are in operation today, covering some 23.5 million lives under Medicare, Medicaid, and private insurers. Although not all ACOs have demonstrated success in delivering better health outcomes at a lower cost, many have achieved promising results (Houston & McGinnis, 2016). As such, significant ACO growth is expected. In fact, it is predicte ...
How Providers Can Reshape their Operations to Master Value-Based ReimbursementsCognizant
Healthcare providers must make sweeping system, process and operational changes to thrive under the inevitable move to value-based payments. Here are our recommendations on how to get started.
Regulatory reforms and advances in technology are enabling a shift from reactive, provider-centric healthcare to proactive, population-based healthcare management. This involves collecting and analyzing patient data from multiple sources to better understand patient needs, identify patterns, and implement preventative programs and automated interventions. The goal is to improve health outcomes and reduce costs by keeping populations healthy and minimizing expensive medical procedures. Healthcare organizations must adopt new data-driven care models, tools, and workflows to effectively manage population health.
Hospitals profitability can be increased by boosting patient satisfaction, reducing readmissions and understanding revenue cycle performance.
In this period of healthcare reform, numerous organizations continue to change their business practices so they can obtain more hospital profitability while also delivering quality care. Healthcare expenditures are expected to reach $4.4 trillion by 2022, and this high level of spending activity has hospitals currently under a lot of pressure to reduce costs.
The document discusses the medical home model as a disruptive innovation for primary care. It proposes paying primary care physicians for coordinating patient care and managing health outcomes and costs through a medical home model. This shifts care from a specialist-focused model to a simpler, rules-based primary care model. The medical home aims to provide integrated, whole-person care through teams led by primary care physicians. It also discusses pilots of medical homes, challenges, and the potential for cost savings through reduced errors, care gaps, and procedures.
Current Trends in Data Protection for Integrated Health, Centralized Peer Rev...PYA, P.C.
A webinar hosted by PYA and the Alliance for Quality Improvement (AQIPS) explored “Current Trends in Data Protection for Integrated Health, Centralized Peer Review Systems, and Other Innovative Programs.” PYA Principal Martie Ross participated in the webinar, which focused on how patient safety organization (PSO) protections can bring value to accountable care organizations and other integrated health systems.
In addition, the webinar provided instruction for using:
Patient Safety and Quality Improvement Act (PSQIA) protections in Medicare Shared Savings Programs, centralized peer review programs, and other collaboratives.
PSQIA protections for new types of clinical analysis, clinical quality reports, and performance tools that contain information that may not be protected under existing state peer review privilege or are shared among an integrated network.
This document discusses 5 elements of a successful patient engagement strategy:
1. Define your organization's vision for patient engagement.
2. Create a culture of engagement within the practice.
3. Employ the right technology and services like patient portals.
4. Empower patients to become collaborators in their care.
5. Continuously evaluate progress and be ready to adapt the strategy.
True patient engagement involves patients managing their own health, a practice culture that prioritizes engagement, and collaboration between patients and providers.
This document discusses various applications of kiosks in healthcare settings. It describes how kiosks can be used for patient check-in and registration to streamline paperwork processes, lower costs, and improve patient experiences. Kiosks are also discussed as a tool for wayfinding within large healthcare campuses. Providing wellness information via kiosks placed in retail stores and pharmacies is highlighted as a growing trend. The document also briefly mentions using kiosks for visitor management and access control. Overall, the key benefits of healthcare kiosks discussed are increased efficiency, lower labor costs, improved language support, faster payment collection, and better delivery of information to patients.
This 17-page document will inspire and guide you through WHY it's time to re-consider your agency technology. Furthermore, this guide will help you answer WHAT you need to know about the shifting home healthcare landscape from a traditional Fee-for-Service model to outcome/bundled reimbursement.
With this guide, you'll learn about topics such as:
1. What is the Bundled Payment Model?
2. Why Home Health Care Agencies Require Technology
3. Steps to Buying a Software Solution
4. Key Factors and Features to Keep in Mind
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How a Real-Time Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
1. HEALTHCARE
PRODUCED IN PARTNERSHIP
WITH LEAVITT PARTNERS
How a Real-Time,
Automated Decision-
Support Tool Can Cure
the Prior Authorization
Time Drain
A pilot program to automate medical and administrative
policies conducted by Cognizant, New England Healthcare
Exchange Network and Informatics In Context revealed
significant time and cost savings. This proven solution can be
scaled to produce effective outcomes for health insurance
companies and providers.
June 2017
DIGITAL SYSTEMS & TECHNOLOGY
2. 2
EXECUTIVE SUMMARY
Many existing prior authorization (PA) processes are comprised of submit-and-forget tasks
that drain time, money and resources, both for health insurance companies and healthcare
providers. Working with the New England Healthcare Exchange Network (NEHEN) and
Informatics In Context (IIC), Cognizant tested a real-time, automated PA system for
medical and administrative policies. At completion, this pilot generated projected savings
of $16 per PA ($9,820 over the span of 597 transactions). Leveraging learnings from this
implementation can help health insurance companies and providers achieve cost savings,
streamline rules and create a more effective PA strategy.
This proven solution can be scaled to include related processes and additional payer-provider
partnerships. By investing in custom-fit PA automations, payers and providers can
streamline requirements, reduce administrative burdens, make rules more transparent and
deliver care more efficiently to patients.
Cognizant partnered with Leavitt Partners, a healthcare intelligence company, to document
this PA solution. This white paper contextualizes these promising results and extrapolates
how other organizations can leverage learnings to implement a PA solution that reduces
waste and helps deliver timely care. Key applied learnings include:
• Commit to a real-time, automated, standards-based solution.
• Integrate clinical and business logic.
• Get buy-in from all relevant personnel.
• Choose your processes intentionally.
• Choose collaborative partners with the right expertise.
2
Digital Systems & Technology
| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
3. “NEHEN’s real-time prior
authorization is the perfect example
of a successful proof-of-concept pilot.
The pilot has shown tremendous
success in automating the entire
prior authorization process and
reducing the need for human touch
points.”
Dave Delano, Executive Director, NEHEN
3How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain | 3
Digital Systems & Technology
4. Specialty Drugs on the Rise
By 2020, nine of the 10 top-selling drugs will be specialty
Source: Drug Channels
Figure 1
2010
2020
Specialty Drugs Non-specialty Drugs
4
Digital Systems & Technology
| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
ASSESSING MARKET NEEDS
Tensions surrounding PAs have intensified over the past several years, as health insurance companies
(e.g., payers) use these processes to rein in costs and avoid the utilization of low-value, overused treat-
ments. The problem with this approach is that it can delay the delivery of care. It has also increased
the administrative burden of getting treatments approved by payers.
Why Prior Authorizations Are Used
An annual survey of 600 large employers by Willis Towers Watson identified minimizing overused
(and often expensive) procedures as one of employers’ major priorities to reduce healthcare costs.1
Additionally, 88% of employers identified managing pharmacy costs (e.g., specialty drugs) as a top
priority. In 2010, 30% of the top-selling drugs were specialty; in 2020, the projection rises to nine of
the 10 top-selling drugs (see Figure 1).2
PAs offer health plans and employers a tool to reduce unwar-
ranted, low-value spending, especially on specialty drugs and overused medical procedures with low
value.3,4,5
Growing Frustration with Prior Authorizations
A risk of reducing expensive medications and overused procedures through PAs, however, is delaying
treatment for patients and exacerbating the administrative burden on providers. Providers indicate
that their staff members spend an average of 20 hours or more per week obtaining PAs.6,7
In a fully
manual process, this includes filling out and submitting supporting documents for each PA request
via paper-based methods.
Likewise, payers receive PA requests, enter them into their care management or utilization man-
agement systems containing business and clinical logic, and then review and approve or deny the
requests. Once a PA request is received by a payer, it can take an average of six to seven days to pass
through the manual review process. Only then can a provider confidently schedule the procedure.
5. “In addition to reducing
processing times, IIC’s automated
platform has exhibited how
clinical information can be
communicated in a more
systematic way. It’s reduced the
need for human intervention,
while still allowing for effective
evaluation of authorizations.
Being part of this pilot gave us
the opportunity to be part of
something that is innovative and
seldom heard of in the world of
prior authorizations.”
Rhonda Starkey, Director of eBusiness Services,
Harvard Pilgrim Health Care
How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain | 5
Digital Systems & Technology
6. 6 | How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
In a series of provider interviews conducted by Leavitt Partners, one of the most consistent frustra-
tions voiced about the payer/provider relationship was the PA process, specifically the administrative
burden it places on providers and inconsistency across payers. In a qualitative study led by the
American Medical Association, poor EHR usability was found to be physicians’ highest source of dis-
satisfaction, followed directly by dissatisfaction with payers. PAs — which fall at the intersection of
these two frustrations — were often cited by providers as a significant burden. Approximately 90%
of the physicians interviewed reported that the PA process sometimes, often or always delays access
to care.8
Not only do delays in access to care impact providers’ ability to effectively treat patients, but they can
also impact providers’ bottom line — negatively impacting providers’ quality measure results.
For example, delays in access to care can negatively impact providers’ ability to score well on
timeliness-of-care quality standards. The 2016 CAHPS Survey for Accountable Care Organizations
(ACOs) asks patients to rate how easy it was to receive timely care and whether they “got answers
over the phone as soon as they needed.”9
Other quality measures require providers to “act early” to
address chronic problems and “facilitate rapid, effective” treatments and “promptly prescribe” phar-
macological interventions.10
Waiting for a PA to be processed directly interferes with providers’ ability
to give a timely response and potentially meet their quality measure standards.
PA processes augment providers’ frustration by increasing administrative burdens, negatively impact-
ing quality measures and taking the provider away from patients to focus on PA processes.
In January 2017, the AMA called for reform, demanding a system that streamlines requirements,
reduces administrative burdens, and increases timely access and transparency.11
Without a federal
effort to streamline PA processes, 28 states have begun implementing their own legislation.12
The
problem with these efforts, however, is that they aren’t synchronized. For example:
• California legislation calls for an electronic submission for medication PAs using a
standardized form.
• Legislation in Louisiana only dictates that a standard form be used, but does not require electronic
submission.13
• Legislation in Massachusetts requires all health plans to use a standardized form, but that form is
onerous for providers to use and doesn’t necessarily coincide with information required by payers.
As such, payers and providers continue to look for solutions to address the PA time drain.
7. Adoption of Fully Electronic Transactions
7How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain |
Unraveling Prior Authorization Processes
Unraveling complex PA medical and administrative policies is an incredibly cumbersome process, with
a mixture of manual and electronic components for each unique provider/payer relationship. Health
systems are increasingly taking advantage of partially and fully electronic PA support tools, with
adoption rates of fully electronic transactions increasing from 8% in 2014 to 18% in 2015.14
However, compared to 2015 reports of fully electronic claims submission adoption (94%) or eligibility
and benefit verification adoption (76%), the low adoption rates of electronic PAs offer an area for
significant cost and time savings as well as the potential to get treatments to patients more efficiently
(see Figure 2). PAs with attachments have shown a high savings opportunity per transaction, with
estimates upward of $45 per transaction.15
PA processes augment providers’ frustration
by increasing administrative burdens,
negatively impacting quality measures and
taking the provider away from patients to
focus on PA processes.
Claims Submission Eligibility & Benefit Verification Prior Authorization
93% 94%
71%
76%
10%
18%
2014 2015 2014 2015 2014 2015
Source: 2016 CAQH Index: A Report of Healthcare Industry Adoption of Electronic Business
Transactions and Cost Savings
Figure 2
8. 8
Digital Systems & Technology
| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
Responding to this need, CAQH CORE — a national initiative to streamline electronic interoperability
— has initiated a series of webinars that evaluate challenges and successes faced while implementing
electronic healthcare claims attachments16,17
and provided an overview of industry efforts to adopt
electronic PA transactions.18
Potential Savings by Switching to Electronic Prior Authorizations
Using staff time and resources to submit, coordinate and follow up on PAs translates into tangible
costs. Both payers and providers could reduce these costs by implementing electronic PA processes.
The 2016 CAQH Index found that health plans could save roughly $90 million, and providers could
save $323 million.19
In addition to potential cost savings, the 2016 CAQH Index reports that both payers and providers
could drastically reduce time spent on each manual PA. Inputting each manual PA takes a provider
an average of 20 minutes per transaction; electronic PA submissions, however, take an average of six
minutes.
Given that providers completed roughly 57 million transactions manually in 2015, they could have
saved 13.3 million hours (798 million minutes) by completing these PAs electronically (see Figure 3,
next page). This estimate, however, does not include time or costs related to preparing materials,
resolving issues or follow-up.
Even processes that use electronic aspects usually include manual components either on the provid-
er’s or the payer’s end. For example, some providers send PAs manually to a clearinghouse or another
partner, which then converts these records to an electronic format for the payer. Conversely, a pro-
vider may have to manually submit information using a payer’s web portal; so while the process is
“electronic” on the payer’s end, the transaction still takes time and resources to be manually inputted
on the provider’s end. Many of these solutions don’t utilize real-time authentication or touchless
technology. If the industry is going to keep up with increasing demands, there needs to be drastic
improvement to prevent a bottleneck of care, mired in paperwork.
When factoring in this additional time and costs, potential industry-wide savings from using a real-
time, automated PA decision-support tool increase astronomically, translating into faster, more
efficient care for patients.
When factoring in this additional time
and costs, potential industry-wide savings
from using a real-time, automated
PA decision-support tool increase
astronomically, translating into faster,
more efficient care for patients.
9. 9How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain |
Digital Systems & Technology
A BETTER WAY FORWARD
Cognizant’s recent endeavor to develop a truly automated, electronic PA solution reveals promising
results. In partnership, New England Healthcare Exchange Network (NEHEN), Cognizant and Informat-
ics In Context (IIC) have created a real-time, automated solution that has shown significant time and
cost savings in addition to other ancillary benefits.
Developing a Real-Time, Automated Solution
NEHEN spent 12 months conducting interviews with payers and providers on what improvements
are needed in administrative data exchange. The interviews uncovered significant efficiency short-
comings in the PA and referral processes. Based on an analysis of these needs, NEHEN, working in
partnership with Cognizant, selected IIC to conduct a proof-of-concept project. The pilot project was
to develop a rules engine to connect with payer utilization management systems, which would auto-
mate payer-specific medical and administrative policies.
Using the decision-support tool developed by IIC, providers enter and upload information specifically
needed for the clinical service PA being requested via a web portal. The web portal allows them to
submit the necessary data to the payer in real time, leveraging standard EDI 278/275 transactions.
IIC helped automate payers’ business and clinical rules to provide immediate feedback for providers,
while following EDI 278/275 standards. The feedback reveals what information is required to process
an authorization approval in real time — thereby eliminating the manual review process, wait time and
follow-up by providers. This approach significantly simplifies administrative processing for payers and
providers, reduces unnecessary delays and lowers costs.
During implementation, NEHEN, Cognizant and IIC collaborated to adapt processes and add abilities
based on user needs. For example, the system allowed a group of providers to identify upcoming
patients that would likely need PAs. The providers could use a batch format, using scheduled patient
appointments, to process patients’ PAs before their appointments. Once submitted in this manner, the
PAs are prequalified by the payer-specific medical and administrative rules before the patients even
arrive for their appointments.
93% 94%
71%
76%
14 x 57M = 13.3MMINUTES TRANSACTIONS HOURS SAVED
Potential Time Savings for Providers Switching to Electronic PAs
Source: Leavitt Partners analysis using 2016 CAQH Index
Figure 3
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| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
Selected Medical Policy Categories
The pilot targeted three high-utilization medical policy categories: home healthcare; select phar-
macy drugs (Rituxan, Aloxi, Emend and Anzemet); and select surgical policies (knee arthroplasty,
varicose vein procedures, breast surgeries, hysterectomies and cholecystectomies) in both inpatient
and ambulatory settings.
Home healthcare — which tends to have more business requirements and fewer clinical requirements
than the other two categories — was chosen due to its high-volume, straightforward nature. The
other two processes (pharmacy and surgical) were selected because of their highly complex, clinical
requirements.
Working with Payers and Providers
While operationalizing the PA decision-support tool, the developers considered provider needs,
keeping the process straightforward, standards-based and automated. The developers also built
in the ability for providers to identify errors before PA submission, prompting them to provide
supplemental information within the transaction itself. This real-time, automated decision-support
tool has increased the number of requests that are auto-approved based on providers’ delivery of
requested data.
Initial pilot project participants included:
• Harvard Pilgrim Health Care (HPHC).
• VNA Care Network.
• Beth Israel Deaconess Medical Center, Department of Surgery and Ambulatory Operations OBGYN
Services.
• Partners Healthcare.
These providers were trained on the system via online webinars, led by a facilitator. Each webinar
included a representative from the participating payer. These 20-minute training sessions walked the
providers through the process, introducing them to the online portal.
Pilot Results: Time and Cost Savings
Pilot implementation — running November 14, 2016, to April 30, 2017 — revealed a drastic improvement
in the PA process, saving participating payers and providers considerable time and costs.
As of May 5, 2017, 82.2% of the pilot’s PA transactions were touchless — meaning they did not require
either payer intervention or provider follow-up. Additionally, the pilot allowed providers to track sub-
missions with real-time adjudication status rather than submitting a fax to request this information,
or not knowing the status at all. Real-time tracking is projected to generate over 85% in cost and
resource savings.
One pilot participant reported that the IIC platform had reduced its processing time from one week to
20 minutes, allowing highly-skilled clinical staff to focus on care management activities rather than
manual processes.
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As of May 5, 2017, 82.2% of the pilot’s PA
transactions were touchless — meaning they
did not require either payer intervention or
provider follow-up.
One pilot participant reported that the IIC
platform had reduced its processing time from
one week to 20 minutes, allowing highly-skilled
clinical staff to focus on care management
activities rather than manual processes.
12. 12
Pre-pilot averages indicated that each transaction could take up to six days to secure PAs; post-pilot
averages report 15 minutes per transaction. CAQH estimates actual costs for both provider and payer
manual processing of PA transactions, with attachments, at $45 per transaction. This pilot used a con-
servative estimate of $20 per manual PA transaction as a baseline for comparison and cost savings.
The results report that of 597 transactions, 491 required no intervention, a net savings of $16 per PA
transaction, or $9,820, conservatively calculated (see Figure 4).
Intangible Benefits
In addition to time and cost savings, intangible benefits from using this automated PA solution were
also realized. Early advantages revealed in the pilot include:
• Easy-to-understand processes and minimized number of input fields.
• The potential to reduce fraud.
• Reconciled requests against payer policies prior to submission, ensuring compliance and reducing
denials, appeals and medical reviews.
• Improved patient outcomes.
• Capacity to concurrently populate payers’ utilization management systems and providers’ com-
plete requests.
• Ability to extend patient visits without additional paperwork.
• Improvements to patient intake and reduced scheduling time.
• Real-time validation, evaluation and adjudication of medical policies.
• Single point of access for PAs and real-time ability to check eligibility.
Provider participants appreciate the partnership they have formed with NEHEN, Cognizant and IIC
through this pilot and have expressed interest in continuing to work on the project post-pilot.
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| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
Calculating PA Process Improvements
Source: Cognizant
Figure 4
Transaction Info As of December 1, 2016 As of January 6, 2017 As of April 30, 2017
Total Submitted
68
(HC-61, Surg-7)
243
(HC-213, Rx-2 Surg-28)
597
(HC-531, Rx-16, Surg-50)
Total Touchless 62 (91.2%) 210 (86.42%) 491 (82.24%)
Requiring HPHC
Intervention
6 33 106
Cost Savings
for Providers
& Payers
$1,240 $4,200
$9,820
(Projected)
13. 13How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain |
APPLIED LEARNINGS
The benefits to providers and payers from utilizing this type of system are transferable to the overall
industry. By implementing a true real-time, touchless, transparent PA system, providers can connect
patients with the right care when they need it, while following proper procedure. As other payers and
providers seek to leverage these benefits, they should consider the following learnings.
Commit to a Real-Time, Automated, Standards-Based Solution
Effective PA solutions are real-time, automated and standards-based. The first two characteristics
save both time and money. The third streamlines and simplifies the integration process, similar to
what EDI 270 has enabled for eligibility checks. To maximize efficiency, payers and providers should
look for PA tools that have all three characteristics.
Solutions that stop short of a truly real-time, automated, standards-based process fail to fully lever-
age cost and time efficiencies. Payers, especially, need to commit to a truly automated system,
investing resources up front and trusting that the return on investment will come. Too often, PAs are
submit-and-forget processes. The best results come from end-to-end solutions, in which the provider
is prompted through all requirements and standards, and receives real-time feedback and direction.
Integrate Clinical and Business Logic
Many PA solutions focus on either clinical or business requirements. The most effective solutions,
however, integrate provider, payer and health system knowledge to provide a singular, streamlined
process.
Each payer’s infrastructure is unique, as are its business rules and personnel jurisdictions. Addition-
ally, providers are often confused or unaware of the payer’s unique business logic. To account for
these individualized systems, PA solutions should integrate the payer’s clinical and business require-
ments. If the electronic solution can prompt the provider on what is needed, the payer’s rules become
transparent and actionable. At the end of the process, the provider is clear on what is and what is
not approved — and why — and can move forward to implement a treatment plan knowing it will be
reimbursed.
Get Buy-In from All Relevant Personnel
Change — even positive change — is hard. And the difficulty that comes with change multiplies with
the more people that are involved. In large organizations, the PA process is often decentralized on
both the payer and provider side, with different people involved in different processes. A crucial part
of implementing a real-time solution is identifying who does what and when, and then aligning all
parties.
• On the payer side, make sure to identify and communicate with everyone that contributes to
both the clinical and business requirements associated with PAs, including the clinical, information
technology (IT), operations and revenue teams.
• On the provider side, invest in training once the PA solution has been implemented. These train-
ings can be conducted in person or through webinars. The more streamlined the process is, the
easier it will be to onboard new providers.
Digital Systems & Technology
14. 14
Choose Your Processes Intentionally
When selecting the PA processes to target for inclusion in a real-time, automated solution, payers
can take different strategies. The key is to intentionally choose a strategy and understand how to
measure its effectiveness. For example, a payer can identify the most complex processes — ones that
require the support of both clinical and medical teams to unravel their internal rules — because these
are the processes that would benefit most from being streamlined. These processes also often have
the highest payoff.
On the other hand, a payer may want to focus first on simple processes that tend to be high-volume,
where mistakes can hide and create a resource-draining, back-and-forth exchange between the payer
and provider.
Choose Collaborative Partners with the Right Expertise
Because payers and providers have unique workflows and each treatment may require individual con-
figurations, it’s critical to work with partners that have both the technical knowledge as well as the
willingness to act and react with flexibility. Each partner organization may have its own expertise, but
they need to share a vision and an agenda. A true partnership brings together a breadth of resources,
where each organization collaborates and is committed to shared success.
Digital Systems & Technology
| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
A payer can identify the most
complex processes – ones that
require the support of both clinical
and medical teams to unravel their
internal rules – because these are
the processes that would benefit
most from being streamlined.
15. 15How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain |
Digital Systems & Technology
LOOKING AHEAD
The potential to scale the pilot’s time and cost savings industry-wide is exciting. Shrinking the PA
window from six days to 15 minutes means that patients can receive care when they need it. Integrat-
ing both administrative and clinical requirements in real-time adjudication also drastically increases
system transparency, alleviating tensions between payers and providers. All these changes mean that
patients can receive more streamlined, time-efficient care.
With a proven solution in place, payers and providers can tackle other medical processes to multi-
ply time and cost savings. By investing in custom-fit PA automations, organizations can streamline
requirements, reduce administrative burdens, make rules more transparent and more efficiently
deliver care to patients.
ACKNOWLEDGMENTS
This white paper was written in partnership with Leavitt Partners, a healthcare intelligence business.
The firm helps clients navigate the evolving role of value in healthcare by informing, advising and
convening industry leaders on value market analytics, alternative payment models, federal strategies,
insurance market insights and alliances. Through its family of businesses, the firm provides invest-
ment support, data and analytics, member-based alliances and direct services to clients to support
decision-making strategies in the value economy. For more information, visit leavittpartners.com.
Note: All company names, trade names, trademarks, trade dress, designs/logos, copyrights, images
and products referenced in this white paper are the property of their respective owners. No company
referenced in this white paper sponsored this white paper or the contents thereof.
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FOOTNOTES
1 High-performance insights — best practices in health care 2016; 21st Annual Willis Towers Watson Best Practices in Health
Care Employer Survey [Internet]. Willis Towers Watson; 2017 Jan [cited 2017 Apr 7]. Available from: www.willistowerswatson.
com/en/insights/2017/01/full-report-2016-21st-annual-willis-towers-watson-best-practices-in-health-care-employer-survey
2 Fein AJ, Ph.D. Future Vision: The Top 10 Drugs of 2020 [Internet]. [cited 2017 Apr 7]. Available from: www.drugchannels.
net/2014/07/future-vision-top-10-drugs-of-2020.html
3 Lotvin AM, Shrank WH, Singh SC, Falit BP, Brennan TA. Specialty Medications: Traditional And Novel Tools Can Address Rising
Spending On These Costly Drugs. Health Aff (Millwood). 2014 Oct 1;33(10):1736–44.
4 Keehan SP, Stone DA, Poisal JA, Cuckler GA, Sisko AM, Smith SD, et al. National Health Expenditure Projections, 2016–25:
Price Increases, Aging Push Sector To 20 Percent Of Economy. Health Aff (Millwood). 2017 Mar 1;36(3):553–63.
5 Mercer | National Survey of Employer-Sponsored Health Plans, 2016 [Internet]. [cited 2017 Apr 7]. Available from: www.
mercer.com/newsroom/national-survey-of-employer-sponsored-health-plans-2016.html
6 Prior Authorization Hurts Patient Care, AMA Survey Finds | Preauthorization, Health Care Companies, Physicians |
HealthLeaders Media [Internet]. [cited 2017 Apr 7]. Available from: www.healthleadersmedia.com/physician-leaders/prior-au-
thorization-hurts-patient-care-ama-survey-finds#
7 Standardization of prior authorization process for medical services white paper [Internet]. American Medical Association;
2011 Jun [cited 2017 Apr 7]. Available from: http://massneuro.org/Resources/Transfer%20from%20old%20sit/AMA%20
White%20Paper%20on%20Standardizing%20Prior%20Authorization.pdf
8 Colligan L, Sinsky C, Goeders L, Schmidt-Bowman M, Tutty M. Sources of physician satisfaction and dissatisfaction and
review of administrative tasks in ambulatory practice: A qualitative analysis of physician and staff interviews. [Internet].
2016 Oct [cited 2017 Apr 7]. Available from: www.ama-assn.org/sites/default/files/media-browser/public/ps2/ps2-dartmouth-
study-111016.pdf
9 CAHPS Survey for Accountable Care Organizations (ACOs) Participating in Medicare Initiatives [Internet]. CMS; 2016
[cited 2017 Apr 7]. Available from: http://acocahps.cms.gov/globalassets/aco---epi-2-new-site/pdfs-for-aco/survey-instru-
ments/2016-aco-survey/english/2016_aco-9_mail_survey_english.pdf
10 Accountable Care Organization 2016 Program Quality Measure Narrative Specifications [Internet]. Centers for Medicare &
Medicaid Services; 2016 Jan [cited 2017 Apr 14]. Available from: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
sharedsavingsprogram/Downloads/2016-ACO-NarrativeMeasures-Specs.pdf
11 Health Care Coalition Calls for Prior Authorization Reform | American Medical Association [Internet]. [cited 2017 Apr 7].
Available from: www.ama-assn.org/health-care-coalition-calls-prior-authorization-reform
12 2017 Electronic Prior Authorization (ePA ) National Adoption Scorecard [Internet]. [cited 2017 Apr 7]. Available from: https://
epascorecard.covermymeds.com
13 ibid.
14 2016 CAQH Index: A Report of Healthcare Industry Adoption of Electronic Business Transactions and Cost Savings [Internet].
CAQH; 2017 Jan [cited 2017 Apr 4]. Available from: www.caqh.org/sites/default/files/explorations/index/report/2016-caqh-
index-report.pdf
15 2015 CAQH Index: Reporting Standards and Data Submission Guide — Health Plans Numbers of Transactions and Costs
per Transaction [Internet]. [cited 2017 Apr 7]. Available from: www.caqh.org/sites/default/files/explorations/index/report/
index_guide.pdf
16 CAQH CORE Attachments Webinar Series Part 1: Laying the Foundation for Electronic Healthcare Attachments [Internet].
Webinar presented at; 2017 Mar 2 [cited 2017 May 30]. Available from: www.caqh.org/about/event/use-and-adoption-attach-
ments-healthcare-administration-part-i
17 CAQH CORE Attachments Webinar Series: Session 2 [Internet]. Webinar presented at; 2017 May 25 [cited 2017 May 30]. Avail-
able from: www.caqh.org/about/event/use-and-adoption-attachments-healthcare-administration-part-ii
18 CORE Participant Call on Overview of CAQH CORE Approach to Adoption of Electronic Prior Authorization Transactions
[Internet]. Webinar presented at; 2017 Jun 19 [cited 2017 May 30]. Available from: www.caqh.org/about/event/core-partici-
pant-call-overview-caqh-core-approach-adoption-electronic-prior
19 Op Cit. footnote 14.
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AT A GLANCE: KEY PARTNERS
Founded in 1998, the New England Healthcare Exchange Network (NEHEN) is a consortium of regional
payers and providers that has designed and implemented a secure and innovative health information
exchange with the intent of reducing administrative costs and improving the quality, safety, and effi-
ciency of patients. NEHEN is known to be an agile, innovative and collaborative organization serving
both payer and provider member organizations. For more information: www.nehen.net
Informatics In Context (IIC) offers payers a transformative standards- based solution that fully auto-
mates their authorization process to become real-time based on the ACA mandated EDI 278 standard
for medical procedures, tests, labs and drugs covered under medical benefits. IIC is able to achieve
a high level of touchless adjudication by automating all of the payer’s policies and guidelines,
including all business and clinical rules, required for real-time responses. For more information:
informaticsincontext.com
Cognizant is a leading provider of information technology, consulting and business process services,
dedicated to helping the world’s leading companies build stronger businesses. Cognizant’s TriZetto
Healthcare Products are software solutions that help organizations enhance revenue growth, drive
administrative efficiency, improve cost and quality of care, and improve the member and patient
experience. For more information: www.cognizant.com
Harvard Pilgrim is a not-for-profit health services company serving members throughout Connecticut,
Maine, Massachusetts and New Hampshire. Our mission is to improve the quality and value of health
care for the people and communities we serve. For more than 45 years, Harvard Pilgrim has built
a reputation for exceptional clinical quality, preventive care, disease management and member
satisfaction, and has consistently rated among the top plans in the country. For more information:
www.harvardpilgrim.org
18. 18
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| How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain
Patricia Doxey
Senior Analyst, Leavitt
Partners
Patricia Doxey is a Senior Analyst with Leavitt Partners, where
she conducts healthcare research and analysis, and writes briefs,
reports and white papers summarizing research. She has over 10
years of experience in technical writing, research and synthesizing
complex information. Patricia holds an M.A. from the University
of Florida and a B.A. from Brigham Young University. She can be
reached at patricia.doxey@leavittpartners.com | www.linkedin.
com/in/patricia-doxey-5a202427.
ABOUT THE AUTHORS
Laura Summers
Senior Director of State
Intelligence, Leavitt Partners
Laura Summers is the Senior Director of State Intelligence, with
expertise in economics, healthcare and public policy. Laura is a
thought leader in state-level health reform, with over 10 years of
experience in research and economic analysis. At Leavitt Part-
ners, Laura has provided project management and research to
assist states design and develop state-based health insurance
exchanges, 1115 Medicaid demonstration waivers and amend-
ments, and other state health reforms. Laura holds an M.P.P. with
an emphasis in public economics from Brigham Young University
and a B.A. from Westminster College. She can be reached at laura.
summers@leavittpartners.com | www.linkedin.com/in/laura-sum-
mers-a412b76/.
For additional information, please contact:
• David P. Delano, Executive Director, NEHEN (ddelano@maehc.org)
• Joel Gleason, Senior Vice President, Cognizant (joel.gleason@cognizant.com)
• Vikram Simha, Founder & CEO, Informatics In Context, Inc. (vsimha@informaticsincontext.com)
19. 19How a Real-Time, Automated Decision-Support Tool Can Cure the Prior Authorization Time Drain |
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