Large Healthcare Payer

Empowering Healthcare Consumers and Their Care Ecosystems With Interoperable Data

What if... we could build an interoperable solution that turns healthcare data into a true strategic asset?

Our client is a healthcare insurance leader committed to the relentless pursuit of quality, affordable, and equitable health care with an unparalleled consumer experience. The company, our client for more than a decade, serves nearly three million members in the northeast U.S.

Forging an Aspirational Foundation for Better Care Experiences

Consumer expectations and interoperability mandates increasingly drive how information is shared across payer and provider ecosystems.

Wanting to do more than simply meet the CMS interoperability mandate, our payer client seized the opportunity to build a scalable infrastructure that mobilizes data in ways that truly put the consumer first – giving all members secure access to their health information when they need it most and in a way they can best use it.

Establishing a Single, Interoperable Source of Truth

Asking the seemingly straightforward question, “What is member data?” quickly unearthed complex challenges for our client. To drive interoperability, the payer needed to consolidate multiple member record inputs – vision, dental, clinical, claims, etc. – so it could meaningfully exchange that information across organizations, systems, devices, and applications in a standardized vocabulary with consistent content. And it needed to follow a similar process for all provider, product, account, and capitation data sets as well.

We were engaged to create a modernized, FHIR-enabled solution that puts the right data in the right hands at the right time.

We structured a solution that ingests, normalizes, and validates data from various internal and external systems to produce a consolidated, reliable data set for use across various touchpoints.

That central source of truth is then shared via API connectors, gateways, and extracts for business- and consumer-facing insights and enhanced experiences.

Surgical Precision to Enhance Member and Business Outcomes

Our interoperability solution securely unlocks data through the core tenants of modernization, optimization, and democratization.

Modernization: We pragmatically focused on key opportunities where a transition from on-premises systems to the cloud will most greatly impact business agility, increase speed to market, improve outcomes, and reduce costs.

We then implemented a cloud-based data management platform that enables batch and real-time streaming with added data security layers. EDI and API platform modernization minimizes downtime and accelerates time to market. Altogether, this solution lays the foundation for multiple systems and dependencies, including interoperable data exchange, a DevSecOps program, and app modernization.

Optimization: The solution gathers data from a variety of disparate internal and external sources. It then builds a normalized data model of consistent common elements and clearly identifies which data source “owns” that truth so that explicit patterns for data integrity can be established and carried forward.

Democratization: We equipped the payer’s teams with a reliable container-hosting platform and built a framework to mask PII/PHI data and keep patient information confidential across platforms and systems. On-premises and cloud-based API management suites and microservices support the creation of winning user experiences via mobile and web applications as well as secure, authorized, FHIR-enabled sharing of data across the full care network.

Our integration and healthcare expertise equipped our client to achieve faster time to market while leveraging its existing enterprise investments. 

Results

Equipping Members and Their Care Ecosystems

The interoperable data solution provides numerous benefits to both consumers and business groups:

  • Powers a more seamless, consistent member experience across all the payer’s digital platforms
  • Provides consumers and authorized third-parties visibility into previous care experiences
  • Enables consumers to manage how their data is shared across systems
  • Facilitates better care continuity when a member moves to a new plan or payer due to a relocation, change in employment, etc.
  • Equips internal teams with reliable source data for billing/financials, personalized marketing and wellness outreach, advanced analytics and propensity models, machine learning, and AI
  • Empowers members and their entire healthcare ecosystem with reliable, efficient, secure data sharing using FHIR standards
  • Creates economies of scale in how the payer can share information across its full stakeholder base

Our client’s aspirational vision for whole-organization interoperability demanded a partner with expertise well beyond FHIR enablement know-how.

Our integration and healthcare expertise equipped the payer to achieve faster time to market while leveraging its existing enterprise investments. We safeguarded a solution that meets all standards and rules when sharing protected health information (PHI). Additionally, our expertise in data governance ensured that data can be trusted and leveraged as a true strategic asset.

These three areas of expertise – integration, healthcare, and data governance – together forged a solution that equips the payer, its partners, and its members for more personalized, meaningful care experiences and better health outcomes.

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