Tag: healthcare

Why HealthEdge’s Acquisition of Wellframe Looks Favorable for Member Experience | Blog

With member experience being critically important to healthcare enterprises, HealthEdge’s acquisition of Wellframe bodes positively for the merged enterprise and consumers. Read on to learn why we like this deal and the synergies between these two health services providers.

HealthEdge’s acquisition of Wellframe announced last month propels the provider of next-gen integrated solutions to health insurers into the high-growth digital member experience market. The deal will bring various benefits to HealthEdge, including Wellframe’s consumer-facing and user-friendly mobile application serving more than 33 million members that delivers personalized content and facilitates seamless connectivity to health plan staff.

The strategic intent behind the deal

In a recent (2020) survey by Everest Group, experience was identified as the most important strategic priority for enterprises. Member engagement has become an important area of investment for healthcare payers. Member experience as a theme is so important that health plans have created a new position, the Chief Experience Officer (CXO), to use their organizational muscle for prioritizing experience.

Healthcare payers realize that great member experience will not only help insurers in smoother acquisition and retention of clients but will also improve their financial performance by reducing the churn rate, improving health outcomes, and saving administrative costs. The industry is also witnessing a shift in the definition of “engagement” from being focused solely on sales and marketing to becoming a holistic approach across the three areas of sales and marketing, services management, and care management.

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The acquisition of Wellframe propels HealthEdge into the large and fast-growing digital member engagement market. Coupled with its existing products, this creates a highly differentiated end-to-end solution for customers.

Unpacking the companies’ synergies

Wellframe’s Digital Health Management platform enables health plans to modernize member-facing services, including care management and advocacy. Wellframe’s Digital Care Management (DCM) solution serves as a digital front door for health plans seeking to engage high-risk members. Wellframe leverages real-time member-generated data and artificial intelligence to identify intervention opportunities across its solution suite.

Wellframe’s data sets of 33 million members combined with HealthEdge’s existing data sets will enable HealthEdge to focus on improving the quality of its insights, helping it not only in care management and member engagement but also in other areas where HealthEdge has traditionally offered services.

The Wellframe acquisition strengthens HealthEdge’s portfolio of SaaS solutions across payer workflow operations. The addition of Wellframe to its portfolio of care management solutions coupled with its existing GuidingCare® solution will enable a full spectrum of services spanning member identification, prioritization, targeting, and member engagement. Additionally, seamless and real-time integration between HealthRules Payor® and Wellframe will generate actionable insights that can lead to real-time member interventions and features that enhance a member’s health plan experience.

Things to watch out for

The acquisition of Wellframe is a strategic fit for HealthEdge to enter the high-growth member engagement market and compete with incumbents in this space, such as Salesforce and Pegasystems.

We are positive about this deal, particularly for what it means to the market and current market demand. However, it remains to be seen if HealthEdge also makes an entry in the other areas of member engagement, such as sales and marketing and services management, which would deliver even greater value.

Reach out to me at [email protected] with your thoughts on this acquisition or the member engagement market in general.

Interoperability in Healthcare – Key Regulatory Implications and Beyond (Part 2) | Blog

The CMS Interoperability and Patient Access final rule has enabled key healthcare stakeholders – payers, providers, and health IT vendors – to realign their strategic goals and work toward enhancing member engagement and care delivery.

While interoperability in healthcare can deliver numerous benefits, complying with the rules can be complex and we are closely tracking this issue. In our earlier blog, we covered the evolution of interoperability over the years, the interoperability rule, and the challenges enterprises face in deciphering this regulation.

Read on for part two in our blog series that focuses on the data sets that need to be shared, steps involved in the data sourcing process, and the areas enterprises must focus on to navigate through the interoperability rule.

Which data gets shared as part of the interoperability rule, and what is the data sourcing process?

The interoperability rule has mandated payers to share across member- and plan-level information with the help of two Application Programming Interfaces (APIs) – patient access and provider directory. The rule also clearly identifies distinct data sets that need to be shared through both the APIs, as illustrated below.

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Having discovered what data needs to be shared, the next big question for enterprises is understanding how to extract this data. To make the necessary data available to its members through open APIs, enterprises primarily have to perform these three key steps: source system identification, data mapping, and data transformation.

  • Source system identification: As healthcare organizations store member information across multiple systems such as claims management system, Electronic Health Records (EHRs), etc., the primary objective is to identify the right source systems that house the information needed to be shared through the APIs
  • Data mapping: Data elements mandated by CMS are populated across various Fast Healthcare Interoperability Resources (FHIR) profiles such as patient profile, practitioner profile, etc. These data elements must be mapped against the respective source systems by matching the fields from the source database to the target database
  • Data transformation: FHIR profiles consist of data elements with attributes such as cardinality, data type, and binding value sets. The mapped data will have to be transformed into the FHIR recommended format by adhering to the data attributes (for example, translation of system codes into industry-specific codes, usage of industry- standard unique identifiers such as National Provider Identifier (NPI), Clinical Laboratory Improvement Amendments (CLIA) number, etc.)

 How do enterprises navigate through the CMS interoperability rule?

Although the interoperability rule defines IT investments payers, providers, and Health Information Technology (HIT) vendors must make, enterprises also need to plan for other critical aspects such as infrastructure scalability and data security in parallel. These areas will be crucial given the increasing data volume and demand for more streamlined services around data access and utilization.

The exhibit below illustrates the key IT remodeling themes and corresponding transformation levers for interoperability implementation in a healthcare enterprise.

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FHIR-based API ecosystem

The interoperability rule states that healthcare enterprises should establish API interfaces for all systems handling member/patient data and that the data transferred among healthcare entities – including the member/patient – should be in a standardized format. A robust API-led interoperability strategy can help healthcare enterprises curb the data liquidity issue within their ecosystems. The FHIR-based APIs will enable data format standardization between different endpoints, decrease development time, and save storage space on endpoint devices.

But just creating and establishing FHIR-based APIs will not suffice. Enterprises need to integrate and orchestrate formats other than FHIR. While connectivity with standard or off-the-shelf systems will be easier, homegrown/custom systems will be challenging to map to FHIR standards. In-house development teams and technology vendors will have to create workarounds to modify existing components that consider the potential variability in medical terminologies.

Infrastructure layer

With the implementation of FHIR-based APIs, enterprises must assess scalability challenges within their existing infrastructures. To accommodate the upcoming member/patient data access requests and enable quick data retrieval, enterprises should start to manage their current data storage and compute capacities. Enterprises can approach the data scalability and infrastructure issue by either leveraging existing infrastructure to build an FHIR-based layer or partner with technology vendors to leverage their data, cloud, or FHIR platforms.

Security layer

As healthcare enterprises will have access to multiple data sources, healthcare interoperability might open the door to security breaches and cybersecurity threats that may not have existed if the data resided within the enterprise. With the influx of data from other healthcare entities, current standard security checks might not be able to cross-reference and validate the identity of the entity requesting access, creating openings for data breaches. To manage these security challenges, added investment in particular focus areas (e.g., application penetration testing, consent management, member education) can help enterprises achieve sustainable data security.

The road ahead

While enterprises are complying with the CMS mandate, an increased focus must be put on how they can look beyond regulations to address some of the key pain points in the industry, such as patient experience, care management and outcomes, and total cost of care. With data flowing seamlessly across the healthcare ecosystem, enterprises should identify and invest in areas that would be crucial to creating long-term business value while also giving them a competitive edge.

As part of our third blog in this series, we will next cover how healthcare enterprises can approach the interoperability rule beyond the mandate to reap long-term benefits, key investment areas, value for enterprises, and an interoperability enablement framework that provides a view into the required IT components for regulatory compliance and what goes beyond regulation.

Please feel free to reach out to [email protected] to share your experience and ask questions.

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