Ravi Agrawal
Senior Manager - Healthcare Practice
A self-confessed healthcare warrior, an expert in Medicare, Medicaid, ACO, and Integration projects, Ravi speaks HL7 as a language. A doctor, d... Read More

Note: This is the first part of a three-part blog series detailing how Nitor Infotech has created a futuristic framework that aims to nullify the challenges of the US Healthcare industry.

Healthcare is experiencing a radical change around the U.S market. A dramatic overhaul of guidelines fused with disruptive digital technologies has caused major changes in the payer-provider model.

Payers and Providers mostly work in silos with restricted patient data sharing – limited to claims and financials. While both of them aim to reduce cost and provide quality care, they face the challenges of having restricted access to patient information. What is needed here is a collaboration in leveraging payer and provider data to assess gaps in care. This could be achieved easily if the data is used meaningfully, for instance if the providers combine EHR and payer data, they would be able to infuse meaningful insights into patient health. It is only possible if the providers start thinking beyond processing the financial information available in the payers data.

Payers are increasingly feeling the need for payer-provider collaboration and are willing to invest and take the initiative to assess the gaps in care, which will lead to improved patient management and lowered claim value.

Nevertheless, there is still plenty of work, which needs accomplishment; healthcare industry conflicts are nothing new. Legislation and technology will continue to modify its landscape. Doctors, and their medical teams must evolve their focus & approach to meet those challenges. Let us have a look at some of the challenges in the current industry workflow.

Ever Changing Compliance

The US healthcare industry is monitored rigorously against stringent regulatory norms. As many of these regulations undergo routine changes, the healthcare industry is under constant pressure to keep up with the changes.

Recent study shows that healthcare executives are additionally burdened to comply with an assortment of freshly revised standards including the Health Insurance Portability and Accountability Act (HIPAA) and many more. On the top of standalone reporting requirements that each of these standards bring in, healthcare providers need to take care of interdependencies as well.

For instance, the healthcare reform legislation increases the number of people covered under Medicaid by more than 25 million. Consequently, the healthcare industry is faced with the prospect of creating, storing, encrypting and protecting 25 million more EHRs. Combine this with the need to report on the actions taken in a regular manner, HITECH compliance will increase volumes in CMS reporting needs.

Data Aggregation & Breaches

 The problem in healthcare lies with the aggregation of the data. To derive insights from data, it is critical that they be accurate and relatively complete. When data is divided and systematically biased through either errors or omissions, the correlations that give rise to new insights will be missed or turn spurious, and could result in misguided confidence or scarce resources dedicated to chasing down dead ends.

Additionally, patient privacy issues, including worries about data breaches, continue to be a challenge for providers & payers.

Providers and payers are constantly looking for the best practices for data security to avoid the type of HIPAA violations that can negatively affect an organization.

Assessing Gaps in Care 

 Health systems are trying to put together integrated techniques to delivering care, which enhance the overall quality for the patient.

The problem that still remains- what level within the provider healthcare system should be held responsible for quality, and how can this be achieved most effectively. One of the major problem is that providers do not have sufficient time to look at the complete health record of a patient and subsequently write a care plan for the patient.

Other most common and prominent difficulties are: data transfer and data merging across different information systems with secure protection of sensitive patient data.

Technology Framework: The Saviour of the Hour

Despite the challenges, many clinicians and health care organizations are making progress by using right technology to provide better care for their patients.

As we charge headlong into the future, those of us in the healthcare industry are striving to create a better system overcoming challenges. Some of the recent use cases are helping to achieve the ultimate goal of quality care and improved patient engagement. Is there a one-size-fits-all solution that can tackle some of the major challenges discussed above?

The answer is Rule Engine – A smart, customizable healthcare data aggregator framework for enhancing patient care journey. Rule Engines help healthcare organizations around the world make better, more informed decisions that increase outcomes, grow revenues, cut costs and liability. Additionally, Rule Engines integrate data from multiple sources providing meaningful insights. This means smarter decisions about products, claims and care in challenging environment.

Let us look at some of the Rule engine use cases, which proves it is a boon.

1) MACRA MIPS Solution:

With CMS introducing MACRA-MIPS program to replace PQRS and other quality programs, providers have turned skeptics. An ideal rule engine allows you to implement MACRA MIPS solution by looking at the available provider data and suggest which rules could be reported to the CMS.

2) Alert Engine:

Prevention is better than cure is a dictum suited to all but what is important is to treat it in time for a higher survival rate. A Rule Engine is capable of setting alerts when patient parameter goes beyond normal range, with the user able to set custom alerts as per standard practices.

3) Financial Reports:

One of the major advantage of the Rule Engine is that it allows setting financial reports as per business needs with custom visualization for the report.

4) Payer-Provider Collaboration:

US healthcare is moving towards patient quality care rather than quantity, complete picture of the patient health; using payer and provider data becomes an important aspect in assessing gaps in care. A rule engine is capable of combining payer and provider data to get complete health record of the patient. It ultimately helps to derive gaps in care, which is the need of the hour.

Importance of Rule Engines and how it changes the dynamics in healthcare

 It is quite clear that a Rule Engine is the solution for the challenges above. Not only does it combine data from multiple sources but also works in real time as per the business needs. It makes it easy for the users to configure rules and set the notifications, alerts, automation, predictive maintenance and much more. An advanced Rule Engine can fulfil that role by ingesting real-time data, reasoning on those data and invoking automated actions based on the result of that reasoning process.

Check out our next blog where we discuss in detail about how an ideal rule engine should look like!

Do reach out to us to learn more about our services.

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