Patient/Payer/Provider Collaboration: The Workflow Tech Angle (Learning Healthcare Systems!)

[This post is part of a series I am writing as a HIMSS17 Social Media Ambassador (four years in a row!) in the run up to HIMSS17, in Orlando, February 19-23. Stop by and meet me at the first ever HIMSS Makerspace, booth 7785 in the Innovation Zone!]

#HIMSS17 is a great opportunity to revisit my 2016 Actuarial Science, Accountable Care Organizations, and Workflow post, in which I predicted what ACO IT will look like in ten years.

(adapted from the The Patient Experience “Stack”)

I’ll recapitulate my five predictions of what ACO IT will look like, in ten years, here.

1. ACO IT will leverage process-aware workflow engines executing models of patient/payer/provider workflows

2. ACOs will simulate behavior of patient/payer/provider workflows to predict population health outcomes and costs.

3. ACOs will focus on patient/payer/provider pragmatic workflow interoperability, not just data interoperability.

See my two five-part series on Task-Workflow Interoperability and Pragmatic Interoperability.

4. ACOs, using activity-based cost integrated with business process management, will know exactly what each patient/payer/provider workflow (enrollment, chronic diagnosis, procedure, claims processing, etc.) costs.

5. Virtual ACO enterprises will systematically optimize system-wide outcomes, experience, and expense across patient/payer/provider workflows. If each of the above predictions, 1-4, become true (workflow tech infrastructure, workflow simulation, pragmatic workflow interoperability, and exact costs tied to specific workflows), ACOs will become truly intelligent learning healthcare systems.

Practically speaking, how does this optimized healthcare workflow nirvana relate to our present circumstances? Particularly regarding payer/provider collaborative workflows?

Let’s take a look at quotes regarding payer/provider collaboration and workflow.


Payer-Provider Collaboration In Accountable Care Reduced Use And Improved Quality In Maine Medicare Advantage Plan

“The patient population in the pilot program had 50 percent fewer hospital days per 1,000 patients, 45 percent fewer admissions, and 56 percent fewer readmissions than statewide unmanaged Medicare populations. NovaHealth’s total per member per month costs across all cost categories for its Aetna Medicare Advantage members were 16.5 percent to 33 percent lower than costs for members not in this provider organization. Clinical quality metrics for diabetes, ischemic vascular disease, annual office visits, and postdischarge follow-up for patients in the program were consistently high.”

Health Data Management:

“No single program reimburses for the end-to-end PHM workflow–and this makes it difficult for physicians and practices to embrace value-based reimbursement…. If payers coordinate their efforts to ensure that, together, their programs reimburse for more PHM workflows and outcomes, providers will have the critical reimbursement mass they need to invest in value-based care.”

From Availity’s blog:

“Providers aren’t taking full advantage of proprietary portals because they have so many different ones to navigate, and each has its own unique design and workflow…. A better approach is a multi-payer platform, which allows providers to log in to one site and process transactions for multiple payers using a common navigation and workflow.”

TriZetto (under the Payer-Provider Collaboration heading):

“bidirectional technology platform enables data availability to provide real-time administrative and clinical tools integrated directly into the physician’s workflow, thereby enabling new care delivery models”

The American Journal of Managed Care (“the leading peer-reviewed journal dedicated to issues in managed care”)

With respect to physician engagement, it was imperative to not change their workflow or at least to find common ground and include them into discussions on why those changes were important

What are some specific payer/provider collaborative workflows that we must support with the right information technology? Here are some examples:

  • Streamline workflows for provider contracting and engagement
  • Support provider workflows directed at optimizing patient experience and engagement
  • Simplify provider workflows for claims and encounter data

Collaboration is intrinsically about workflow. Therefore it’s worth reviewing the Wikipedia entry for Collaborative Workflow.

“Collaborative workflow is the convergence of social software with service management (workflow) software.”

“collaborative workflow is derived from both workflow software and social software such as chat, instant messaging, and document collaboration”

The goals of collaborative workflow include:

  1. “Improving effectiveness on joint tasks by removing the communication barriers between team members
  2. Minimizing organizational boundaries and information silos
  3. Allowing online social interaction to be goal oriented, structured, and measured”

“collaborative workflow is a collection of parallel and sequential tasks that rely on communication and coordination to achieve a desired outcome”

Finally, the attributes of a collaborative workflow management system include:

  • Collaboration to accomplish defined goals or tasks
  • Management of a collaborative goal, task, or project from start to finish
  • Integration of collaboration and workflow objects within a secure framework for enterprise applications
  • Project and task infrastructure enabling work to be accomplished in an organized fashion (in contrast to pure-play social software)
  • Skill-based task assignment to teams or individuals
  • Ad hoc projects that span organizational boundaries, and minimize information silos

All of these attributes apply to streamlining, supporting, and simplifying patient/payer/provider collaborative workflows. A goal may be getting well or getting paid. End-to-end, start-to-finish, interacting clinical and financial workflows are the key. We need to model, execute, monitor, and improve all workflows, including patient/provider, patient/payer, and payer/provider. Due to the sensitive nature of this clinical and financial information, we must do so within secure enterprise infrastructure. Social collaboration, even secure social collaboration is not enough. Workflow models must capture and observe healthcare organizational goals and constraints. Roles, of patient, of provider, and of payer, must be modeled and used to drive the right task to the right person at the right time, and make sure it is done right. However, at the same time all this workflow structure is imposed, exceptions and ad-hoc interactions, among patient, provider, and payer, must also be expected, handled, and supported gracefully.

Obviously, APIs (Application Programming Interfaces) are essential to exposing and updating data about patients, providers, and payers within their respective, evolving IT systems (see How Easy Is It To Integrate Availity APIs Into Your Payer-Provider Workflow? Very!). However, APIs are just half the IT battle, when it comes to workflow.

Without workflow, data is just another bottleneck.

It will be the marriage of both data technology and workflow technology that will deliver on the promise of truly optimal collaborative patient/payer/provider workflows.

Luckily, this marriage is happening. Every year since 2011 I’ve searched every website of every exhibitor at the annual HIMSS conference. I look for workflow-related content and trends. A wide variety of collaboration and workflow software vendors are showing up at HIMSS17 for the first (and, by now, even a second or third) time. And a wide variety of indigenous health IT vendors are adding collaboration- and workflow-related functionality to their products and services.

Great collaboration and great workflow, among patients, providers, and payers, requires great collaboration and workflow technology. Look for it.

@wareFLO On Periscope!


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