Humana’s Low-Code Partnership Approach to Rapid Digital Innovation

In an era of rapid digital healthcare innovation, Humana, the third largest health insurance company in the U.S. faced several challenges within its digital channels unit to rapidly bring new solutions to market. It was laden with complex architecture, which meant IT had to tread carefully, given the importance of safeguarding personal health information for millions of members.

Amid this complexity and the COVID-19 pandemic, Humana needed a solution for its contact center’s number one ask: locating a COVID-19 testing center for its members.

The existing giant spreadsheet was slowing down contact center staff, so Humana turned to its low-code delivery partner, Cloud Development Resources (CDR)—an Emids company—to co-deliver a solution on the OutSystems platform. Through this low-code co-creation approach, Humana was able to create the web app experience on OutSystems in a weekend and Emids was brought in to develop a full suite of back-office functions, allowing 30 reps to regularly update the testing locations database in real time on the web app.

Within a month, Emids also created a mobile-friendly customer-facing app to help members directly find testing sites through a Google-map-like search experience leveraging artificial intelligence in OutSystems.

Speed to market is a key challenge for digital innovation and Humana now delivers four times faster for its members thanks to a low-code platform approach to application development and its partnership with CDR. This shows that a vast range of innovations once considered cost-prohibitive or risky are now viable. Finally, Humana now has a mobile-friendly customer-facing app that allows members to self-serve, taking pressure off of their call center agents.

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Learn more about the partnership between CDR, OutSystems and Humana here.

Medtronic Seamlessly Integrates Nerve Monitoring System Data with Backend EHR

Medtronic is the largest maker of surgical equipment in the world. One of its offerings is a nerve integrity monitoring (NIM) system to help surgeons avoid accidents that can impede or even end nerve function for patients during surgery. 

With its existing product, operating room staff copied reports from the NIM to the EHR using a USB memory stick or by printing and then scanning reports, but neither approach was elegant or efficient. Medtronic wanted to explore a more seamless integration between its NIM system and backend electronic health records (EHR).  

That’s where Emids came into the picture.  

Emids set up an on-site alignment workshop where it explored a range of options for integrating the NIM into back-end EHR systems. These included cloud-based solutions, Interface Engines, FHIR and HL7—two data-interchange standards commonly used in healthcare. Emids created a proof-of-concept dashboard for device-specific information. This cloud-based functionality took only a week to develop and showcases some of the potential benefits of cloud-based service and support for Medtronic. 

“Cloud integration gives us business intelligence we’ve never had before, and that opens the door to all sorts of possibilities, from better product planning to novel revenue models.”

Paul Cox

Former head of software development & architecture, Medtronic

Following the workshop, Medtronic settled on a combination of FHIR integrated into the NIM units for patient record lookup to prevent patient mismatches—important because patient mismatches increase the complexity on data submission—and HL7 to do the actual data updates. Within a few months of starting the project, Emids had designed and built a working prototype for the next generation NIM. 

The new device allows reports to be uploaded to a hospital’s EHR system over Bluetooth or Wi-Fi with a couple of button presses. And it is future proof too, since FHIR is quickly becoming one of the most popular standards for health data exchange.

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Experience Design of a Direct-to-Consumer Care Portal

Emids worked with a top Fortune 500 payer organization, which aims to empower their over 100m members to live healthier lives.

The organization wanted to complement its care advisors with a high touch, digital concierge experience for families experiencing complex care needs regardless of their health plans. The objective was to free up space for the provider and specialty-care practices so they could focus on care delivery and member health.

Selected for its deep healthcare domain and user-centered design expertise, Emids took a deep dive into the portal’s existing experience and also assessed user challenges through a month-long discovery session.

 

Throughout the discovery process, Emids focused on the journeys of prioritized users to identify opportunities for delivering a better user experience. Emids created user scenarios and flows to describe an ideal experience from the users’ perspective and prepared necessary UX requirements and recommendations to support future product development efforts.

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Through continued collaboration with the client team, Emids delivered a UX Playbook to serve as a reference point for product decisions going forward, including research findings and recommendations and design decisions. Emids also delivered two prototypes to reference for the MVP and Beyond the MVP work, highlighting key service design considerations as the project continues into the build phase.

Digital Front Door Solution for a Rapid Access Addiction Medicine Clinic

One of Canada’s foremost mental health care facilities approached Emids for support to improve the lives of those living with mental-health illness and addiction. 

The pandemic restricted in-person access to medical care for those dealing with drug and alcohol related addictions, exacerbating their plight. The rate of opioid-related overdoses also rose significantly in the months following the declaration of the pandemic. The facility wanted a solution that allowed it to deliver care virtually. 

Emids was brought in to develop a digital solution that leveraged the facility’s Rapid Access Addiction Medicine (RAAM) Clinic to deliver care virtually to patients. 

With the RAAM Clinic, Emids leveraged its design-led engineering approach and user experience design knowledge to transform the client’s workflows into a digital front door experience. This means the same services are now delivered remotely over the internet on both desktop and mobile devices. 

Patients can check into the RAAM Clinic on a device with internet access and a camera, answer a few screening questions and submit any related insurance information before being connected with a clinician who will assess their individual needs. 

The solution also allows patients to connect with additional care team members including addiction counsellors, social workers, nurses and physicians, as well as allowing for additional support members such as friends and family to attend the sessions.  

The digital front door solution—built on Emids’ HealthConnect Platform-as-a-Service that accelerates the creation of Digital Health solutions—is highly instrumented. This means that various key performance metrics are captured so the system is continuously improving itself. 

In the case of the client, the facility successfully pivoted from in-person care to digital care using the RAAM Clinic. The client was highly satisfied delivering care virtually at a time when it was most needed. 

Taking a Design-Led Approach to a Provider Portal Experience

Availity, a benefits and claims management platform, facilitates over 4 billion clinical, administrative and financial transactions annually for their payer & provider network.

Facing market pressure from customers and competitors, Availity wanted to take a blue sky approach and reimagine their provider portal to reduce the overhead that resulted in calls to support. They turned to Emids for their design-led approach to product creation.

Emids and the Availity product team worked to ideate, research, and deliver on an experience prototype, initially solving for a narrow slice of the workflows that could be scaled to the entire platform. 

With an advisory committee, composed of existing end users spanning organization size and specialty, the Emids team implemented an agile, iterative design and research framework that allowed for the quick creation of design concepts that could be tested with end users before the next iteration.

The final experience design was delivered in the form of a clickable Invision prototype.

End users were delighted by the reimagined portal experience, remarking how quickly and frictionless formerly confusing processes were made, which will no doubt reduce the need for phone calls to health plans for support.

Compliance with CMS Interoperability & Patient Access Final Rule

Overview

The Emids client is a not-for-profit 501c3 health maintenance organization (HMO) insurance company with a consistent record of earning accreditation by the National Committee for Quality Assurance (NCQA).

Emids partnered to help them build the right capabilities that comply with Centers for Medicare and Medicaid (CMS) regulatory requirements related to Interoperability and Patient Access final rules. These regulatory requirements are applicable to the client’s LOBs – Medicaid and Duals only.

The Challenge

Developing interoperability preparedness for not only regulatory compliance but “beyond the rules” readiness.

Emids Solution

Our team performed a discovery assessment to understand as-is state and data ingestion process, data flows, technology and integration tools. We carried out a detailed assessment around FHIR integration, “Build on Cloud” solution approach, and discovered FHIR resource gaps within the current data landscape.

Based on our analysis, we explored multiple options to comply with the CMS Interoperability mandate, developed a future state architectural blueprint, identified selective use cases related to regulatory mandates and created a detailed implementation road map, including an overall operating model.

Our team implemented a selected interoperability solution option including cloud infrastructure setup, building authentication and authorization mechanism using OKTA, implementing an FHIR server for exchange as well as storage of healthcare data exchange and exposing data using FHIR compliant APIs. This solution approach was forward-thinking to anticipate and build new member engagement and data analytics capabilities down the line.

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Results

In 10 months we helped the client meet the Patient Access API & Provider Directory API deadline of CMS mandate.

Enterprise Clinical Data Exchange

Overview

The client is one of the nation’s leading operators of general acute care hospitals. The organization’s affiliates own, operate or lease 84 hospitals in 16 states with approximately 13,000 licensed beds.

As part of a multi-year partnership, we develop and support HL7 interfaces to expedite a Promoting Interoperability Program for clinical data exchange. This program prevents delays in execution by EMR vendors to provide Public Health Reporting (PHR) services due to a lack of PHR expertise and inability to accommodate frequent changes in the regulations.

Emids Solution

​Our team developed an HL7 interface on Lyniate Rhapsody and Mirth Connect to enable Promoting Interoperability Program-related Clinical Data Exchange. We also developed interfaces for the following programs – Syndromic Surveillance, Immunization Registry, Immunization Query, Electronic Laboratory Reporting, and National Hospital Care Survey.

20,000+

completed maintenance and support of 20,000+ HL7 Interface.

Results

Our team performed interfaces development for 6 programs supported under MU3  – Syndromic Surveillance, Immunization Registry, Immunization Query, Electronic Laboratory Reporting, National Hospital Care Survey. We successfully helped the client meet state-specific deadlines for COVID-19 case reporting and managed frequent changes in data specifications by the DOH.

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Clinical Data Acquisition & Integrations

Leveraging the AWS Cloud platform to help leading medical organization accelerate growth and cut operational costs costs

Overview

The Emids client is a leading national medical group with more than $5 billion in revenue. The group provides physician-led services, ambulatory surgery center management, post-acute care and medical transportation among other services. The client encounters more than 30 million patients annually across the U.S.

But the client faced several data challenges impeding its long-term growth.

The group’s clinical data exchange had more than 1,100 point-to-point connections to support data acquisition and had more than 600 sites reporting Medicare-Access-and-CHIP-Reauthorization-Act/Merit-based-Incentive-Payment-System data via a paper-based abstraction process. Additionally, the client was losing revenue from delayed billing caused by incomplete data as well as minimal to no internal checkpoints on data feeds.

Emids Solution

That’s where Emids was brought on to serve as a strategic data partner.

Our team adopted a consulting-led approach to identify key stakeholders, conduct interviews, understand the state of data acquisition & ingestion, clinical flows, technology and integration tools. We carried out a detailed assessment of Health Information Exchanges (HIE), Epic App Orchid, Cerner Hub and other data sources as identified by the client.

We defined a new strategy for real-time data acquisition and developed a data-acquisition roadmap illustrating data feeds. We recommended a structured format of electronic health records data for acquisition. This included using Epic APIs and the Epic App Orchard and a Fast Healthcare Interoperability Resources (FHIR) based implementation strategy, HL7 for Cerner HUB and CCD-based strategy for HIE’s.

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The solution was built on the AWS cloud platform leveraging S3 for storage, RedShift for data warehousing, Athena for interactive analytics and a host of other AWS services like Lamda, Glue, and Kinesis data streams.

Results

Emids became the client’s strategic data partner for more than two years, resulting in scalable FHIR-based solutions hosted on the AWS platform. This reduced effort and increased savings on operational costs.

Enhancing the Overpayment Recovery Process to Result in Savings

Overview

The Emids client is a pharmacy benefit manager and care services group with over $100 billion in revenue. They have three main businesses, all of which strive to deliver transformational healthcare solutions and improve outcomes while lowering costs. We have partnered with the client for over 10 years, during which time they have provided data mining and overpayment recovery services for physicians and facility claims for three specific lines of business – employer and individual, Medicare and retirement and administrative services.

Our team had been auditing all client-paid claims to providers using various algorithms and business rules as a part of the overpayment recovery process. For the algorithms coordination of benefits (COB) and member’s eligibility/coverage-related (Retro Term), auditors used consumer database (CDB) – a Web-based application – as the source for accurate coverage data and relied on the information available at the time of the audit. CDB was updated whenever a change in information occurred, such as new member coverage. The client then provided a member analysis report in which external vendors identified the overpaid claims that were initially rejected (considered paid correctly) by our auditors, based on the information stated in the CDB.

For each overpaid claim identified by an external vendor, the client was paying a premium which led to revenue loss.

Solution

Our team analyzed the situation and realized that if all rejected claims from COB and Retro Term were re-audited with a lookback period, an opportunity existed to identify overpayment for those specific claims in which member information was updated after our audit, and before the external vendor began identifying the rejected claims.

They subsequently tweaked the current process by introducing a re-audit, during which COB and Retro Term rejected claims were reviewed with a lookback period of two months, considered the standard timeframe to upload the member’s updated coverage information in CDB. Also taken into account was the standard lag time for the external vendor to begin identifying the rejected claims. Based on past data analysis, our team identified that claims valued at more than $5k, which comprised 2% of the total inventory covering 45% of the total claims value, could be re-audited to reduce the revenue leakage.

Enhancing the Overpayment Recovery Process to Result in Savings

Our project team members were trained in COB and Retro Term algorithms and given access to all required applications to complete the re-audit.

Results

By introducing a re-audit of the overpayment recovery process, our team has saved the client $885k to date without impacting productivity, turnaround time and quality metrics.

Enhancing the Overpayment Recovery Process to Result in Savings

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Recognizing When to Establish a Member Interaction Center

Overview

The client is a large payer national healthcare organization that needed to maximize the application of the member engagement dollar. This challenge created the need for the company to establish a Member Interaction Center (MIC).

This initiative also required that the current member engagement process be optimized to ensure the engagement dollar is spent to create the largest possible impact on the health of members. This had to be accomplished through the most effective channel, deploying the right sequence of engagement. The goal was to ensure that teams and care agents were able to productively engage members and were performing at their best.

We discovered this problem existed after a team of architects, business analyst and functional experts met with health management executives and IT leaders from the client team. These leaders were interviewed to identify the existing process and operational issues, resulting in the discovery of the need for requirement elicitation in conjunction with the customer team. The requirement was to develop a MIC.

The client needed to solve numerous problems, including:

We realized that numerous successful end results needed to be accomplished:

Solutions

We developed several effective solutions that significantly enhanced the client’s MIC. Four primary solution pillars were considered – efficiency, quality, maximization ROI realization and cost management. Efficiency solutions included sustaining technology with the existing infrastructure and optimizing the Netezza platform to power the analytics warehouse. Quality solutions centered around the structured processing of data and developing a configurable and tool-agnostic solution. Maximizing ROI realization consisted of developing a quicker time to market and the standardization of the data operation process with maximum automation. Cost management solutions involved minimizing operation and engineering expenses and reducing infrastructure costs.

Results

Our successful functional and technical solutions met the client’s goal of maximizing utilization of the member engagement dollar. We saved millions of dollars on member engagements and optimized channels for outreach.

Functional solutions

The MIC solution integrates data from various streams like Wellness and Preventions, Care Management, Disease Management, Member Management, Agent Productivity, CCC, Preferences and Campaign Effectiveness into the Member and Health Management Data Mart to provide insight to business leaders in understanding agent effectiveness and productivity through a well-crafted dashboard.

Technical solutions

The proposed MIC solution architecture will involve data extraction from hetrogeneous data feeds (internal and external), data processing and loading data to the Federated Warehouse and Data Marts (DM). The newly built data marts will provide the KPIs for creating Tableau-based dashboards.

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