blue slate health it award winning payer case study

© Blue Slate Solutions 2010December 7, 2010

The Road to TransformationEnsuring your infrastructure will meet business vision

today and tomorrow

© Blue Slate Solutions 201022

About Blue Slate Solutions

Liz Gaudet• Healthcare Leader at Blue Slate• 26 years multi-payer experience• Business process and strategy focus• Passionate about your success

Clientele

4 of the top 20 health payers including 7 BCBS plans 2 of them in the top 3

Experience

100+ healthcare-specific projects25+ different healthcare entities

Dave Read, CISSP• Blue Slate CTO and Chief Solution Architect• 20+ years tech leadership experience• Strategy and technology focus• Passionate about governance and security


Will current architecture serve future business vision?

40 year old US payer, 2500+ employees across multiple locations serving several million subscribers

Our client

How can we surpass our competition?


Grounding

Strategy

Applications

TechnologiesCurrent State

Organization

Two tracks; one destination

Business Technology


Technology Methodology


Technology methodology

Examine technology capacity and flexibility

Assess applicationfunctionality and data

Discover IT organization’s alignment and skills


Architectural maturity model: transformational change

Business SilosStandardized

TechnologyOptimized Core

Business

Modularity

IT CapabilityLocal IT

applications

Shared technical

platforms

Companywide

standardized

process or data

Plug-and-play

business process

modules

Business

Objectives

ROI of local

business

initiatives

Reduced IT costs

Cost and quality

of business

operations

Speed to market,

strategic agility


Systems and stovepipes

Call Center TechnologyEDI Systems Mainframe Systems

Department 1 – Imaging, Workflow

LOB 2

LOB 1

Department 2 – Portal and eServices

DWH- Informatics

MYSE Core Services (data tier)

DDI (current)

EDI Gateway Mainframe Programming

Other Corp Tools...

IVR / VRU

ETL

Analytics & Stats

Claims - Initial

Claims Processing secondary

Extract

NT-Agg

NTI

NT2

NT2A

Doc WFEInbound Paper Appeals

Inbound Paper – Claims

Inbound CORR EDI

Inbound Paper– Finance

Inbound paper – Enroll

Inbound Corr – Other

Inbound Paper COB

Escalation Inquiry Tracking

ADI-C#

Portal Services

Notification Email Tracking

Call Center Inquiry Tracking System

Medical Review Tracking System

LOB 1 Appeals System

DDI (rewrite)

COB Tracking System

INV Tracking System

FIN Tracking System


Redundancy creates fragility

System A

System B

System C

System D

System E

Corporate data

Corporate networks and infrastructure services

Data

Applications

Technology platforms


Manual workflow

Document due dates /timeframes

Quarter EndInitial Due

Date-

Last Date to Enter-providers will go on

Warning

Withholding Date - 15 Calendar

days

Summary Report Due

Date - Due 45 days after

Initial Due Date

Demand Letter Due

Date

3/31/2009 4/30/2009 5/15/2009 5/30/2009 6/14/2009 6/29/2009

6/30/2009 7/30/2009 8/14/2009 8/29/2009 9/13/2009 9/28/2009

9/30/2009 10/30/2009 11/14/2009 11/29/2009 12/14/2009 12/29/2009

12/31/2009 1/30/2010 2/16/2010 3/3/2010 3/16/2010 3/31/2010

3/31/2010 4/30/2010 5/16/2010 5/31/2010 6/14/2010 6/29/2010

6/30/2010 7/30/2010 8/15/2010 8/30/2010 9/13/2010 9/28/2010

9/30/2010 10/30/2010 11/15/2010 11/30/2010 12/14/2010 12/29/2010

12/31/2010 1/30/2011 2/15/2011 3/2/2011 3/16/2011 3/31/2011


Business Methodology


Business methodology

Ground leadership in possibility

Conduct cross-functional interviews

Discover and validate strategy


Organizational maturity model: transformational change

13

Level 1Informal/Ad hoc

Level 2Formal/Documented

Level 3Integrated

Level 4Strategic

Level 5Optimized

PeopleIndividual Success“Fire fighting is a way of life.”Uncoordinated relationshipsIn competition

Enterprise CollaborationHighly AgileStrategically focusedRewarded on Enterprise Success

Process and Technology

Ad HocChaoticInconsistent

AdaptiveOpportunisticProactiveAgile

Communication Ad HocChaoticNo single source of truth

PreventiveHighly AdaptiveOpportunisticCommunity based (All stakeholders)

Measurement Ad HocManualPeople-based

Data is used to evaluate and select process improvements

Budget Ad HocUncoordinatedHidden spendIndividual Project based

OpportunisticStrategically Focused


Business tract findings

Cascading impact

System count high (2X)

Homegrown % high (70+%)

Process standardization low (1:2 average uses/application)

Process integration low (forced manual tracking/reporting)

Architectural and talent investments not fully leveraged

Opportunities High for Transformation

Scalability

Agility

Reporting

Bottom Line

Business needs not being met today or tomorrow


aligns transformation

Definition of future state

Iterative roadmap to target architecture


building blocks

• Deep departmental process understanding• Uncover/Redirect current manual process labor• Retain transitional value non-core point solutions

• Extranet Leadership• Diversified LOBs• Outsourcing Experience

Leverage

Org

aniz

atio

n Fu

nctio

ns

• Structured EA transformation plan• Organizational level work processes (all receipt mediums)• Single sources of truth (data integrity)• Organizational Integration / Sourcing• COTS Component Architecture (ECM, BPM, BRE, BI/DW)• STP / Exception Processing / DRY/ Case Management• Program / Change Management /Project Governance

Indu

stry

Target

• Separation of Work (LOB, Department, etc.)• Lack of Document Association (Manual)• High Pain/Cost Process Decentralization• Security Breaches, Process/Control Gaps• Document centric workflow, manual data collection

• Silo-based IT investment, Multitude of systems/apps• Disparate Data• Redundant Data Entry • Architecture Limitations and Cost Implication

Mitigate

Org

aniz

atio

nFu

nctio

ns


Operating model: key informer for architecture


Target architecture

EIS TierHost Systems

OLTP data sources

OLAP data sources

LDAP repositories

Security Service

Workflow Engine

Rules Engine

Document Mgmt System

Logging Service

Provider Data Service

Enterprise System Components

Claim Data Service

Services / Business Tier

Messaging

Other Services…

Integration Tier object domain

native/proprietary domain

Presentation Tier

Application TierRequest Tracking NRQT ID Notifiier

MAD …

WSOnline Provider

Services iPhone Android Facebook

PersistenceTransactionsCategorizationIndexingSecurity

Data abstractionDAOTransactionsSecurity

AggregationBusiness RulesSDOWork FlowTransactionsSecurity

ViewLayoutSecurity

canonical data models

O-R O-XML O-Unstructured O-API / WS O-Screen Scrape

ETL

Member Data Service


Unified data speeds integration

Medical Review Claims Provider Unique business

processes

Shared data

Standard canonical data formats

Common, shared data and canonical data formats


Channels shouldn’t matter

call center

email

portal

image

IVR

One process, manychannels / contexts


Avoid the Big Bang

Align

Architect

Iterate

Apply 80/20

Measure


Actionable


Maturity and relative IT spending


The business operates, but how?

Classic Optimized

Rules Mostly human with some static systems

Automated, flexible, DSL with human for exceptions

WorkflowManual, escalation by complaint, process knowledge by experience within department

Automated, SLAs, consistent, cross-department

Documentation Paper-based, curriers, access challenges (timeliness, copies)

Electronic repository, single location for all documents, effective retention and security

Communication Ad-hoc, broadcast, many pull requests Just-in-time, targeted

SystemsStove-pipe (department, purpose and technology), redundant functionality, duplicated or inaccessible data

Shared services, integrated data, systems of record


Level 1Informal/Ad hoc

Level 2Formal/Documented

Level 3Integrated

Level 4Strategic

Level 5Optimized

People

Individual Success“Fire fighting is a way of life.”Uncoordinated relationshipsIn competition

Roles well understoodCoordinated RelationshipsPerformance MeasuredStandardized training

Program level CoordinationCommonality driven Customer focusedRules assume low level tasks

CollaborativeAlignedData drivenThinkers vs Doers

Enterprise CollaborationHighly AgileStrategically focusedRewarded on Enterprise Success

Process and Technology

Ad HocChaoticInconsistent

EmergingStandardizedIsolated Repeatable

DefinedStructuredMeasuredCompetent

AlignedDisciplinedPredictableQuantitatively Measured

AdaptiveOpportunisticProactiveAgile

Communication

Ad HocChaoticNo single source of truth

Common language emergingGaps understood and reconciledQuality checks

Common languageStandards TrainingTied to PerformanceSystemic Quality ChecksShift burden to Supplier

Aligned across and outside Enterprise

PreventiveHighly AdaptiveOpportunisticCommunity based (All stakeholders)

Measurement and Control

Ad HocManualPeople-basedSilo

StandardizedRepeatable Emerging proactivelyEmerging AutomationPortfolio

Proactive AlignedAutomatedEnterprise

Qualitative assessment

Data is used to evaluate and select opportunities

Budget

Ad HocUncoordinatedHidden spendIndividual Project based

Emerging Spend VisibilityCoordinatedEmerging ControlCoordinated Projects

Clear Spend VisibilityProgram ApproachControlledROI visibility

AlignedPredictableAgile

OpportunisticStrategically Focused

Resulting transformational maturity progression

25

2b

7 6

1

2a

2

2a

2a

8

5


Kick-start techniques

Leadership

Qualifiers and competes

High-value data

Key process standardization

Commodity technology

Meaningful POC opportunities


The value of Blue Slate

Blue Slate brings…

External view

Broad experience

Focus

You receive…

The BluePRINT

Enabling greater…

Level of competitiveness

Leverage of existing systems

Efficiency and utilization


What’s on your mind?

? ?

blue slate health it award winning payer case study

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