a story of partnership: healthinsight

A Story of

Partnership

Who is HealthInsight?

➢We are a private non-profit organization, acting as a catalyst in the

redesign of health care systems with a long track record of

participation and success in the Medicare QIO program.

➢We have been national performance leaders, piloting innovations,

sharing knowledge, and promoting program advancements

through the years.

Who is HealthInsight?

The federally-designated Quality Improvement Organization

for three states (NV, NM, UT) with more than 40 years

experience.

Also contract with 27 other

states’ QIOs to handle

their appeals on weekends

and holidays.

What does HealthInsight do?

➢Our current work includes serving as an:

– Medicare Quality Improvement Organization

– State External Quality Review Organization;

– Regional Extension Center (REC) for Health Information Technology;

– National ONC Beacon Community; and

– Community health information exchange (HIE) organization

– NRHI regional health improvement collaborative;

– AHRQ-designated Chartered Value Exchange (CVE);

– RWJ Foundation Aligning Forces for Quality community;

➢Forty years experience working in the federal Medicare

program.

We are experienced, successful agents for change

Improved System Performance

Relationships

Payment

Alignment

Copyright HealthInsight

The Quality Assurance Division

Medical Case Review – improving care one case at a time.

➢Patient and Family Engagement and Immediate Advocacy

➢Complaints Investigation (Quality of Care)

➢Expedited Appeal of Discharge/Termination of Service

Determinations • Process over 1000 cases monthly, more cases than any other QIO,

• Cover appeals under subcontracts with 27 other QIO’s and provide

mitigation review for conflicts of interest cases for 21 states

Appeal Example

• Sally is Medicare beneficiary living alone who was recently admitted to a hospital after a fall during which she broke her hip.

• The surgery went well and after a week the hospital provided her with a notice that her Medicare provided services would be terminated the following day

• Sally doesn’t feel ready to go home and requests an appeal of the termination

• She calls the Medicare Helpline (rings at HealthInsight) requests an expedited appeal of her discharge/ service termination notice

• HealthInsight processes the appeal (requests and redacts medical records for the physician reviewer; requests and records the physician review; notifies the beneficiary and providers of review outcome; updates government system with case details; sends written notices to case parties, if required)

• Sally receives a call from a HealthInsight nurse saying that her independent Physician Reviewer agrees with the planned discharge/termination of services and if she stays in the hospital she will be responsible for paying any for the services she receives after the day on the termination notice.

What we had?

HealthInsight leads the nation in development and use of technology to

support electronic case review and drive efficiency in the Quality Assurance

Our Dilemma?

➢Current application is built on Lotus Notes

– Medicare will not approve Lotus Notes for external web use

– Relies on a Lotus Notes freelancer for maintenance

– Can’t respond to change requests

– Can’t keep up with regulations updates and state specific customizations

➢Want to scale their business to all 50 US states

➢Expand business beyond Medicare

Additional Business Challenges?

• The life cycle of a review request typically lasts 1 to 3 days

• HI is only paid if cases are processed in a timely manner; penalized if

case processing does not meet Medicare Regulatory SLAs

• Physician Reviewers must be paid regardless

• All medical records supplied by Medicare providers must be “redacted”

• Numerous government rules and regulations must be observed

• Physicians receive and respond via email or fax; manual data entry

• CMS does not allow any direct integrations; duplicate and manual data

entry required

• CMS still requires providers to FAX in medical documentation

Lotus Notes Screenshot

Appeals Screenshot

Look-up Info

Use of whiteboards and loose leaf

sheets to track and keep users

updated on latest information

Business Rules

Business rules end up as

reminders on various

computer “sticky” notes

Our Solution!

HealthInsight engages OutSytems to help us migrate off the

Lotus Notes platform

Our Approach?

➢Requirements Gathering Session

➢ Initial walk through of the old application

➢Workflows – business process documentation –

old and new

➢Defined Sprints and Epics

➢Based on assumptions supported by industry

standards and experience

➢Timebox of 3 months

➢2 full time developers

➢1 full time delivery manager

➢1 part-time engagement manager

Expected Business Process

Support & Clinical Staff Administrator

High-level Architecture

Expected Feature Usage

Source: Standish Group Study Reported at XP2002 by Jim Johnson, Chairman

Features and Functions Used in a Typical System

Actual Detailed Business Process

Actual Feature Usage

Features and Functions Used by Hi-Resolution

INFREQUENTL

ALL DAY

WEEKLY

MONTHL

END OF

Other Challenges

➢PDF document manipulation (upload, merge, manipulate,

preview)

➢ Inbound fax queue management and outbound faxing

➢Automatic processing of inbound emails

➢Specific UI requirements – ➢ Specific screen sizes

➢ User guidance that supports process flow

➢ User role business functions can overlap

➢ Lock indicators for cases

➢ Information rich pages and entry forms

➢ Users with low technology proficiency

➢Extensive audit logging

➢Many, many business process exceptions

➢Support for IE8 and IE9

Was this a gamble?

How we got it done!

➢ Incredible team work and work effort between

business and development teams

➢Delayed vacations

➢Early mornings and late nights and some

weekends

➢Extreme categorization of defects and requirements

for prioritization

➢Willingness by business to live with some

problems and do some things manually

➢Compromises in functionality to simplify the design

➢ Increase of timebox by 1 month of development time

for stabilization and issue resolution

New HI-Resolution Application

2013 Rollout Plan

Development & Testing Go Live

Tuning

Rollout

What we accomplished?

• Migrated all business functions off Lotus Notes

• All key functions can be performed in the new application

• Established the baseline to which HealthInsight will be able

to add:

• Additional functionality - like external access for

physician reviewers

• Additional contracts (states) for which to process

appeals

• Additional types of processes besides appeals

What we accomplished?

• Some Statistics

• Almost 170 user stories

• Managed over 400 defects and change requests

• Processed 1400 new cases in the first month

What we learned?

➢Having IT infrastructure in place is “critical”

➢Things aren’t always as simple as they seem

➢Managing timelines, competing priorities and goal

conflicts

➢The old adage of “Test early and often” still holds true

➢Test early on the same type of equipment that the users

will be using

➢Targeting old browser versions with a new application

wastes time

➢When replacing an application, you cannot always count

on some functionality not being needed.

➢A sense of humor goes a long way

➢Wine, port and chocolates help make up for lost sleep

Questions?

a story of partnership: healthinsight

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