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
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.
Developing interoperability preparedness for not only regulatory compliance but “beyond the rules” readiness.
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.
In 10 months we helped the client meet the Patient Access API & Provider Directory API deadline of CMS mandate.
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Enterprise Clinical Data Exchange
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.
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.
completed maintenance and support of 20,000+ HL7 Interface.
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
The Emids client is a leading national medical group with over $5 billion in revenue. They provide a wide array of healthcare services, including physician-led services, ambulatory surgery center management, post-acute care and medical transportation. Their physicians, advanced practice providers and support teams are responsible for more than 30 million annual patient encounters across the U.S.
As a strategic partner for over two years, Emids streamlined its clinical data exchange with 1,100+ point-to-point connections to support data acquisition. With over 600 sites reporting MACRA/MIPS data via a paper-based abstraction process, this was unsustainable for the customer growth journey. A primitive clinical data exchange mechanism also led to revenue leakage due to delayed billing caused by incomplete data and minimal to no internal checkpoint on data feeds, leading to data quality issues.
Our team adopted a consulting-led approach to identify key stakeholders, conducted interviews, understand as-is state of data acquisition and data ingestion process, 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.
Based on our analysis, we defined a new strategy for real-time data acquisition and a data acquisition roadmap detailing data feeds. We recommended a structured format of EHR data for acquisition such as Epic APIs and the Epic App Orchard and FHIR based implementation strategy, HL7 for Cerner HUB and CCD-based strategy for HIE’s.
Our team designed a highly scalable FHIR-based interoperability solution hosted on the AWS platform to overcome multiple P2P connections, hence reducing effort and saving on operational costs.
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Enhancing the Overpayment Recovery Process to Result in Savings
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.
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.
Our project team members were trained in COB and Retro Term algorithms and given access to all required applications to complete the re-audit.
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.
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Recognizing When to Establish a Member Interaction Center
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:
- Inability to effectively utilize the data sets available and monetize them
- Existence of a fragmented process flow and inconsistent collection of member engagement data
- Excess administrative costs due to lack of integration between member interaction function and other departments, such as eligibility and enrollment
- Absence of insight concerning ROI on investments and effectiveness of member engagement initiatives
- Lack of centralized repository for PHM analytics
We realized that numerous successful end results needed to be accomplished:
- Developing a 360-degree Member-Engagement Analytics Platform
- Transforming a seamless integration of heterogeneous systems into an analytics platform
- Conducting data profiling to determine data availability and usage
- Evaluating various off-the-shelf tools and other technologies based on the data and functional requirement along with client infrastructure and technology, from which the solution was determined
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.
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.
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.
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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Understanding the Challenges of Data Migration
emids delivered a GUI-based ETL middleware tool which leveraged Microsoft SQLServer, Snaplogic and a .Net interface.
One of the main reasons many organizations, especially at the enterprise level, continue to use older or legacy systems is the challenge of updating all of the “jobs” or interfaces which move data into and out of those systems. From years of work and work-arounds, these interfaces become complex and patched with custom coding. Much of the cost, time and risk in any digital transformation is found in this area making data migration one of the greatest challenges. The underlying process is called Extract Transform and Load or ETL.
At the same time, interface work is often thought of as basic blocking and tackling work in many IT departments and is often not considered as prominently as other parts of the system modernization. This is combined with the reluctance of data trading partners to change the incoming feeds or doing so at a cost for many of the same reasons. The basic work of ETL can often become a drag on implementations due to the effort involved in both documenting and accommodating clients who also are slow to change.
Business rules, or the Transformation component of ETL, can end up in multiple IT systems and either lost in layers or trapped in legacy systems. Because they are built over time, there is a tendency to either add on to a very long and complex “rule” or to create a new “purpose-driven” task each time. Either path adds to the complexity and creates a process dilemma. The skills and the knowledge for transformation work are often split between the technical IT and business analysts. This often leads to having purpose-driven interfaces as the analyst attempts to replicate IT functions and use the technical tools directly, or the IT resource creates rules on the analyst’s behalf over and over via individual requests.
Our client, an enterprise healthcare payer/provider, was one of the organizations going through the process of modernization of their IT infrastructure and clinical delivery systems. The UM platform was replaced and interfaces had to be migrated. A new interface management and ETL tool, Snaplogic, was also implemented across the enterprise. As part of those efforts, they recognized that there was an opportunity to not repeat the past, and a need for a tool to migrate the interfaces to the new platform without repeating the process dilemma of purpose-driven interfaces. The purpose of the tool was to create a method for analysts to onboard customers and set up file transfers, or interfaces, without the need for purpose-driven coding.
We were engaged to build a GUI-based ETL middleware tool which leveraged Microsoft SQLServer, Snaplogic and a .Net interface. Middleware, in this context, is software that operates between the data source and the target system and allows communication that is not dependent on the two systems having a common structure. The middleware solution acts as a translator between the two systems and transformations are typically applied as the data moves from system to system. Middleware solutions can also be made available to the analyst to apply their contextual knowledge without having the overhead of ETL and IT administration.
We started by examining the capabilities of Snaplogic and the existing processes to discover the business context and the actual rules. We then looked into applying a master set of rules globally but instead opted to design a framework so that, by entering configuration details into the application, complex and custom rules were applied to any incoming feed in a generic fashion. We also designed the capability of using MDM-governed or core tables to consolidate multiple, independent incoming feeds into a single stream to the target UM system. The configuration also includes steps to validate the incoming records and diverting potential errors to a path for correction.
By using the application framework we developed, analysts are now able to set up new customer feeds and connect to sources, move and archive files, apply transformation rules, validate data, load to targets and manage job scheduling without manipulating the underlying infrastructure. The resulting tool is a significant reduction in both development resource cost and time to implement new, and eventually change existing, customers.
This innovative no/low code approach keeps the technical delivery in the framework, which reduced the IT support load, and allowed analysts to create and manage the process without assistance in all but the most difficult scenarios. By consolidating the rules within the framework, auditing and reporting of the specifics was simplified and could be more readily understood by both technical and business users. This was accomplished by applying a generic approach to the process while still allowing individual customizations to be applied in a standardized format.
The engagement entailed extensive development, testing and component integration between the application, database and Snaplogic. This tool was not only delivered on time and on budget, but also met all functional requirements and attained all goals and objectives initially established by the client.
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Our client is a Fortune 500 payer and is a leading provider of traditional and consumer-directed healthcare insurance plans and related services. This includes medical, pharmaceutical, dental, behavioral health, long-term care and disability plans, provided primarily through employer-paid (fully or partly) insurance and benefit programs and Medicare. The organization’s network includes 22.1 million medical members, 12.7 million dental members, 13.1 million pharmacy benefit management services members, 1,200,000 health-care professionals, over 690,000 primary care doctors and specialists and over 5,700 hospitals.
At emids, we have a team of ServiceNow experts who help organizations implement IT Service Management solutions via the ServiceNow tool designed to boost IT productivity and performance, and the overall impact of IT, by automatically assigning mundane tasks such as routing requests to relevant assignment groups and auto-categorization.
The client had been utilizing our ServiceNow tool to manage information technology services for various subsidiaries for a number of years. However, following an acquisition by another large organization, they embarked on a series of integration projects that challenged the tool’s ability to scale quickly and effectively.
Three primary issues concerning the usability of the ServiceNow tool needed to be addressed:
- Lack of innovative speed and scale due to disparate ServiceNow instances. Use of different ServiceNow instances meant reliance on multiple point tools, making it difficult to support new innovation. Manually routing and categorizing incidents is quite time-consuming.
- Absence of visibility creating risk and keeping IT stuck in maintenance mode. The organization stored data in multiple systems, making it difficult to get a single, actionable view of their IT performance.
- Increase cost of ownership on old applications with outdated hardware. Significant time and resources were being spent maintaining existing IT systems without receiving new benefits.
We developed three effective solutions that significantly increased the client’s usability of the ServiceNow tool.
First, we created a broad IT app portfolio on an extensible, scalable platform that future-proofs the organization’s investment. Our solution was to help the client easily extend its IT management capabilities without having to invest in costly and complex integrations and hardware. This was achieved by bringing data and processes into a single ServiceNow instance.
Next, we produced a single system of action and machine learning, allowing fragmented data to be replaced by automated work. We enabled the organization’s IT services to be managed from a single system of action with simplified reporting and machine learning, driving higher levels of automation.
Last, we achieved security and domain separation to ensure personalized services to subsidiaries. A domain-separated infrastructure made it possible to deliver services fast, with built-in proven practices, from a secure cloud with 99.995% uptime, all while ensuring employee records, service catalogs and workflows were customized to meet the needs of each subsidiary.
Because of our proposed solutions, the organization can now:
- Drive digital transformation and new efficiencies with automation. We helped the company drive automation and gain more visibility into IT performance. By gaining more insight into service metrics, it became easier to implement new innovation and improve customer satisfaction.
- Deliver reliable IT services quickly from any device, anywhere, at any time. The client can now find and resolve IT issues more quickly than ever before.
- Manage continual improvement using built-in analytics and shift the budget to innovation. With a single ServiceNow instance, the organization realized infrastructure cost savings simply by having to pay for a single instance, saving up to $500k in the process.