HMIS [Health Management Information Systems]: Linking Payers and Providers

1. HMIS [Health Management Information Systems]:Linking Payers and Providers December 2009 Dennis J. Streveler

2. 2009 UPDATE • Deflation of computer costs continue • Emergence of mobile phone technologies • Near ubiquity of Internet connections and the emergence of “cloud computing” • New “open source” applications for healthcare • Further progress with the Electronic Medical Record and Telemedicine

3. 2009 CHALLENGES REMAIN • Support and sustainability of computer systems in many environments is still poor • Healthcare systems, especially payer information systems, remain among the world’s most complex systems • Reliability of communications channels is often over estimated

4. Four Goals of HMIS

5. Three components required:

6. SYSTEMS INTEGRATION! • These 3 components must be thought of as ONE effort, since they will closely interlock with each other. • The development of these 3 components must be synchronized with each other – having one advanced component while the others lag will not provide the desired result!

7. Integration enhances synergy through inter-operability!

8. What is a claim?

9. BASIC PROVIDER SYSTEM FUNCTIONALITY • Enrollment, patient registration and eligibility checking • Appointment scheduling • Claims creation and submission • Payment processing • Contract monitoring and negotiation • Business-unit management • Inventory management

10. ADVANCED PROVIDER SYSTEM FUNCTIONALITY • Electronic Medical Record • “Health Passports” • Clinical Guidelines and Protocols • Telemedicine (telehealth, teleconsultation)

11. PAYER SYSTEM FUNCTIONALITY • Beneficiary Management: Registration and eligibility • Premium contribution collection • Contracting and contract management • Claims adjudication and management • Fraud detection and provider profiling • Provider payments • Utilization management • Case management • Quality management • Fund management

12. THE ELECTRONIC LINK BETWEEN PAYER AND PROVIDER • Sharing of patient eligibility and rosters • Transmission of claims to the payer • Transmission back of anomalies and errors • Transmission of payments from the provider to the payer • Transmission of utilization management and quality assurance data from payer to provider (“the report card”)

13. OPTIONS FOR “THE LINK” • Point-to-point connections • Passive “hub” for switching transactions • A “smart” central clearinghouse which does some edits and audits of information as it is passed through.

14. CONNECTIVITY OPTIONS OPTION 1: Inefficient point-to-point communications OPTION 2: A “star network” clearinghouse

15. Project Guidance

16. Project Guidance

17. Cost Guidance

18. IN CONCLUSION • Three synchronized HMIS activities must occur to optimize the electronic flow of information to support provider payments: • Providers must have systems • Payer(s) must have systems • The systems must be able to “talk to each other”

19. IN CONCLUSION • Costs and implementation timeframes can vary widely based on environmental, technical, organizational and political factors. • It has become nearly impossible to implement a modern strategic purchasing protocol (provider payment scheme) without employing modern information systems!