Category: Uncategorized

In today’s fast-paced environment, where data transfer is vital for efficient operations, HealthEdge recognizes the importance of providing high-speed connectivity options to its customers. While the standard VPN connection has served well in the past, it may not always meet the needs of customers requiring rapid and large-scale data transfers. To address this challenge, HealthEdge offers a dedicated point-to-point circuit, enabling superior performance, monitoring capabilities, and troubleshooting between HealthEdge and customer data centers. In this blog post, we will explore the market and business background of HealthEdge’s high-speed connectivity options, the associated benefits and differentiation, as well as how these solutions work.

A Bit of Background

Historically, HealthEdge’s software solutions have relied on VPN connections to connect with customer data centers. While VPNs have been effective for many customers, they do pose constraints when it comes to transferring large amounts of data quickly. HealthEdge now offers high-speed connectivity options to cater to the specific needs of customers with demanding data transfer requirements. By providing dedicated point-to-point circuits, HealthEdge ensures that customers can transfer data swiftly, enhancing operational efficiency and minimizing any bottlenecks that may arise from slower connections.

Top 5 Value Points of High-Speed Connectivity

HealthEdge’s high-speed connectivity options come with several significant benefits that set them apart from traditional VPN connections. Let’s explore some of these benefits:

1. Secure User Authentication: HealthEdge employs OpenID Connect and/or SAML2.0 protocols for user authentication. These protocols are industry-standard and provide a secure and open authentication framework. By leveraging SAML and OpenID Connect, HealthEdge enables customers to authenticate users via a secure Identity Provider (IdP) managed by the customers themselves. This approach ensures that sensitive credentials are only sent directly to the customer’s IdP, enhancing privacy and minimizing the risk of storing data within the application.
2. Payer Authentication Delegated to Customer’s IdP: HealthEdge’s high-speed connectivity options allow customers to apply their own password policies independently, without HealthEdge’s involvement. Additionally, by relying on the customer’s chosen IdP, which specializes in secure industry-standard authentication, the burden of implementing and maintaining advanced security methods rests with the IdP. This arrangement ensures that customer data remains safeguarded while benefiting from the economies of scale and expertise provided by the IdP.
3. Multifactor Authentication (MFA): HealthEdge supports the use of Multifactor Authentication as an optional layer of security. MFA requires users to provide two or more categories of authentication to verify their identity. This can include something the user possesses (e.g., a unique token from a third-party application) or something they are (e.g., a fingerprint or retinal scan) along with a standard user ID and password. By implementing MFA, HealthEdge adds an extra layer of security, ensuring that access to sensitive data, such as ePHI (electronic Protected Health Information), is limited to authorized personnel only. This aligns with regulatory requirements such as HIPAA compliance.
4. Just-in-Time (JIT) User Provisioning: HealthEdge’s high-speed connectivity options streamline user access management and identity governance. JIT user provisioning automates the process of managing users in the health plan’s system, saving time and reducing the workload for administrators. This efficient approach frees up valuable resources for other critical tasks.
5. One-Time Single Sign-On (SSO) Configuration: HealthEdge’s SSO configuration is a one-time activity. Once implemented, the same configuration works seamlessly across all of the health plan’s environments, including Production, Pre-Prod, UAT, Dev, and Test. This externalized configuration approach accelerates deployments and upgrades and reduces operational costs.

How it Works

To initiate the process, HealthEdge first assesses the best carrier option available in the geographic area. Based on this evaluation, HealthEdge will order a dedicated circuit from the chosen carrier. The dedicated circuit serves as the primary connection, enabling high-speed data transfer between HealthEdge and customer networks.

Once the carrier is selected and the circuit is ordered, HealthEdge provides the customer with connection details, including addresses and routing information. The customer is responsible for setting up a Layer 3 connection point within their data center. This connection point serves as the entry point for the dedicated circuit and facilitates the transfer of data between HealthEdge and the customer’s infrastructure.

In addition to the connection point, a Network Address Translation (NAT) IP address is required as an endpoint for routing traffic. The NAT IP address ensures that data is directed correctly between HealthEdge and the customer’s networks, enhancing the efficiency of data transfer.

The dedicated circuit serves as the primary connection between HealthEdge and the customer networks. This dedicated circuit offers superior performance and reliability, ensuring fast and uninterrupted data transfer. However, to further enhance resilience, HealthEdge also establishes an IPsec VPN tunnel as a passive redundant connection. In the event of the dedicated circuit becoming unavailable, the IPsec VPN tunnel acts as a backup, enabling continued data transfer.

Moreover, HealthEdge maintains a secondary IPsec VPN tunnel. This secondary tunnel remains disabled under normal circumstances. However, it can be enabled if the primary data center experiences an outage or during disaster recovery testing. By leveraging this setup, HealthEdge ensures continuous connectivity and data transfer, even in the face of unexpected disruptions.

To learn more about how HealthEdge’s new high-speed connectivity offering, visit www.healthedge.com or email us at [email protected].

 

In a recent webinar titled “Navigating Value-Based Care Through Technology and Automation,” Dr. Sandhya Gardner, MD, Chief Medical Officer at HealthEdge Clinical Solutions, and Mr. Jeff Rivkin, Research Director of Payer IT Strategies at IDC Health Insights, shared valuable insights on the current state of value-based care and the role of technology in its implementation.

The webinar kicked off with Jeff highlighting the advancements payers have made in recent years in value-based care. Payers are transitioning from being merely transactional entities to becoming active partners in care. With the advent of exchanges and marketplaces, payers have focused on improving the shopping experience for enrollment as well as the overall patient satisfaction and engagement. The rise of convenience as a leading factor in healthcare decision-making has led to the emergence of models such as retail health, telehealth, hospital at home, and care anywhere, all aimed at providing accessible and patient-centric care. Additionally, payers have been actively engaging in interoperability, striving to establish an open and seamless system where data can flow between payers, providers, and patients. Artificial intelligence and data analysis have played a crucial role in leveraging payer data to identify care gaps and predict patient needs.

The Role of Technology in Value-Based Care

According to Dr. Gardner, technology plays a pivotal role in facilitating the transition to value-based care by automating manual workflows and leveraging data. Technology can support the efficient delivery of care and improve patient outcomes, while also improving the reach of care management teams by identifying and stratifying at-risk populations. Modern care management solutions offer configurable algorithms to rank member risk based on multiple data sources, including clinical diagnoses, pharmacy claims, and health risk assessments. Digitalizing the intake process and automating care plans can further streamline care management workflows, making them more efficient and increasing member engagement and satisfaction.

Harnessing the Power of Data

Health plans have access to vast amounts of data, ranging from patient experience surveys to medical and pharmacy claims. The challenge lies in sifting through this data to identify relevant and actionable insights. In the webinar, Dr. Gardner emphasized the importance of leveraging data to drive quality improvement rather than merely focusing on compliance. She highlighted the need to surface the right data to the right stakeholders at the right time, enabling health plans to improve performance and outcomes across populations. For instance, data capture can aid in identifying gaps in care and leveraging technology to close those gaps. HealthEdge’s solutions provide configurable assessments and gap closure functionalities, empowering health plans to enhance quality and performance scores while improving patient outcomes.

Adapting to Regulatory Changes

The speakers discussed how technology can assist health plans in adapting to value-based regulatory changes. Examples included incorporating health equity stratification data into assessments to address disparities in care quality across different racial and ethnic groups. Furthermore, modern technology can help health plans meet the requirements of Medicare Advantage and ACA 2023 regulations, particularly in collecting social determinants of health data through health risk assessments (HRAs). Another critical aspect is provider data management and directory requirements, under the No Surprises Act, where HealthEdge’s upcoming provider data management solution can help health plans ensure accurate and up-to-date provider network information.

Accelerating the Journey Toward Value-Based Care Success

This webinar shed light on the progress health plans have made and the opportunities they have in front of them as they pursue their value-based care strategies moving forward. As payers continue to evolve toward become active care partners, embracing convenience and interoperability to enhance patient satisfaction and engagement is critical. Technology solutions have enabled the automation of manual workflows, streamlined care management, and facilitated data-driven decision-making. By harnessing the power of data and leveraging advanced technology, health plans can improve quality, outcomes, and member experiences in the value-based care landscape.

To access the full webinar on-demand, watch the recording here. If you’d like to learn more about how HealthEdge can support payers with value-based care, visit www.healthedge.com.

Creating an Interoperability Strategy that Delivers Results: How to Prioritize Integrations within Care Management and Across the Healthcare Ecosystem

To achieve seamless care coordination, reduce costs, and increase efficiencies, care management platforms must integrate effectively within care management functions as well as across the entire healthcare ecosystem. However, identifying and prioritizing the right integrations can prove challenging for health plans. To get the most out of an interoperability strategy, health plans should understand market drivers and establish goals for what should be accomplished through enhanced integration.

After working with many health plans on developing and executing their interoperability strategies, we have a thorough understanding of how the most successful plans view interoperability.

With the right integrations in place, health plans can break down siloes, support new regulations and payment models, and improve the member experience.

The Race is On: Market Dynamics and Priorities Driving Urgency for Interoperable Care Management Systems

New regulations, evolving payment models, and shifting member expectations are driving urgency for health plans to advance interoperability across multiple systems. For example, the recently proposed CMS rule, “Advancing Interoperability and Improving Prior Authorization Processes,” will prompt health plans to address integration gaps in their prior authorization and utilization management processes. In addition, the transition to value-based care demands more advanced interoperability to allow for better collaboration and outcomes.

Meanwhile, payers are also investing in strategies that improve health outcomes and member experience to advance ratings in the CMS Star Ratings program. Star Ratings can have a significant financial impact for health plans, as moving up from a 3.5- to 4-star rating is worth an additional $400 per member per year on average for Medicare Advantage plans. With member satisfaction and care outcomes being key drivers of the health plan rating, many are finding interoperability to be a critical investment for advancement in these core areas.

Finally, innovation in digital experiences and rising consumerism in the industry continue to shift to member expectations of access to health data and information from across the broader healthcare ecosystem. Members are seeking ease of access to their health and claims data, making efficient exchange of information a top priority.

Integrating the Care Management Function

When building a successful integration strategy to address these needs, health plans should first consider several key integrations within the care management function. These integrations facilitate better care coordination, improve communication, and ultimately optimize health outcomes. To begin, payers should consider how their core care management platform will integrate with solutions housing these types of data:

Social Determinants of Health (SDOH): According to the National Academy of Medicine, new payment models are prompting health plans to prioritize strategies to improve the social wellbeing of their members. SDOH account for approximately 80-90% of a member’s overall health, with medical care accounting for only 10-20%. As a result, many health plans are elevating the importance of investing in ways to enable members to manage aspects of their environment that contribute to overall health.

By systematically integrating care management with SDOH data,  care coordinators can deliver more whole-person care and services by supporting social and economic needs that contribute to a member’s health status. By quickly and easily connecting members with social services, enabling seamless data exchange, and tracking and measuring progress, care coordinators can support overall health needs of their members.

Clinical Criteria: Integrating care management with clinical criteria platforms enables health plans to streamline utilization management (UM) workflows, while informing care strategies that improve outcomes for members and reduce costs for health plans. The integration has become more critical for health plans as costs continue to rise and health plans seek new strategies for improving efficiencies.

Lettering & Correspondence: Timely, clear, and effective communication can advance member engagement, a key factor when it comes to improving overall health outcomes. Integrating care management with lettering and correspondence solutions allows efficient creation of personalized member mailings. Streamlining the process of delivering real-time correspondence for denials, appeals and grievances, and other member communications strengthens member engagement and saves time for health plan administrators.

Business Rules: When business rules are seamlessly integrated with a care management platform, health plans can more effectively manage complex care, automate best practices, and streamline the prior authorization process. Improving efficiencies through this level of integration enables health plans to make strides in preparation for new CMS guidelines to improve processes and efficiencies related to prior authorizations.

Business Intelligence: Health plans are managing more data than ever before. To unlock insights and intelligence behind the data, health plans require use of advanced tools. Integrating reporting and business intelligence allows health plans and care managers to easily access and use the real-time data to improve care management strategy and workflows.

Prioritizing Integrations Across Healthcare Ecosystem

In addition to interoperability within the function, care management solutions should integrate with platforms across the healthcare ecosystem to improve efficiencies and reduce costs. As health plans build their interoperability strategies, health plans should prioritize integrations with other functional systems, including:

Core administrative processing system (CAPS): Integrating claims data into care management workflows allows care managers to incorporate indicators such as repeat provider visits, lack of medication adherence, and missed encounters to create the most effective care plans. With access to the complete view of member history and claims data, care managers can make more informed decisions. Efficient exchange of this type of information is integral to the success of value-based care.

Payment integrity platforms: Interoperability between care management and payment integrity platforms ensures payment teams can access real-time clinical data. As a result, they can improve the accuracy of the claim, configure more effective benefit packages, and reduce provider and member abrasion. The integration also improves efficiencies and reduces costs by eliminating manual data entry.

Digital health management tools: The availability of digital tools and remote monitoring devices for connectivity to patients continues to grow exponentially. With better access to patient data from multiple sources, care managers can more effectively care for members and improve outcomes. According to HIT Consultant, “Creating and utilizing clinical-grade digital health innovations increases adherence and provides members with more accessibility. By utilizing things consumers already have – such as smartphones and videoconferencing platforms – these innovations can create new pathways to care.” Integrating care management platforms with innovative digital health tools not only improves member satisfaction, but also promotes better health outcomes and care quality. By delivering results in these areas, health plans can support value-based care and boost Star Ratings.

Delivering Interoperability Strategy with GuidingCare®

GuidingCare takes a multi-faceted approach to interoperability that includes both integrations within the care management function, as well as those across the entire healthcare ecosystem. With more than 75 unique vendor integrations and 12 productized integrations, and 75 API endpoints to integrate content into native workflows, GuidingCare provides the tools and resources health plans need to successfully execute their care management interoperability strategies.

To learn more about how about how GuidingCare’s highly interoperable platform can accelerate your organization’s care management strategies, visit the GuidingCare page on the HealthEdge website.

Legal compliance refers to the adherence to laws, regulations, and standards that are applicable to a specific industry or organization. At HealthEdge, Compliance is an essential component of business operations, as it helps to mitigate legal and financial risks and ensures HealthEdge operates ethically and in the best interests of stakeholders.

What is Legal Compliance at HealthEdge?

Legal compliance is the ongoing process of ensuring that a company, business, or other organization is adhering to the applicable laws, regulations, and industry standards. This can include complying with financial reporting requirements, implementing privacy and security safeguards, training workforce members, and conducting operations in accordance with the numerous laws that govern businesses, such as employment, tax, and insurance laws.

The purpose of having a strong compliance program is to help organizations operate at a high level and to avoid the penalties, financial losses, and reputational damage that can result from violations caused by non-compliance. The financial penalties for violations can be significant and have the potential to cause additional harm that can be devastating to the success of a business.

A quality compliance program provides assurance to prospects and customers that a business is well-managed, trustworthy, and reputable. A compliance program can be tailored to support an organization maintain its ethical standards (like transparency, honesty, and respect) which also helps build trust with stakeholders, customers, workforce members, and shareholders.

HealthEdge prioritizes compliance throughout the company so that all workforce members are aware of and involved with its success. The compliance group takes a cross-functional approach to engage company-wide support and increase the efficiency of compliance efforts. By working with multiple departments, HealthEdge ensures that the compliance requirements are met, and regular work is unaffected so business can continue as usual.

HealthEdge is committed to working for the best interests of its customers, and the strength of its compliance program helps demonstrate that commitment.

How does HealthEdge achieve Compliance?

Implementing company-wide compliance is a complex process that requires knowledge and awareness of the many laws, regulations, rules, and standards that require strict adherence. HealthEdge takes a detailed approach to ensure the compliance program is performing at a high level, and that the compliance program is working as intended. The program is designed around the seven foundational elements of a compliance program outlined by the United States Sentencing Commission, incorporating an additional element from the Department of Health and Human Services (HHS) Officer of Inspector General (OIG) Compliance Guidelines:

1. Governing Authority: HealthEdge has a Compliance Officer (CO) and the Risk Compliance and Governance Committee, that is comprised of members of the executive leadership team is responsible for the execution, correction, and oversight of all aspects of the compliance program.
2. Policies and Procedures, and Code of Conduct: HealthEdge commits to complying with all applicable federal and state regulations and standards–this includes providing guidance to workforce members on compliance-related matters. HealthEdge also provides procedures that assist in the identification and correction of non-compliance. These policies and procedures are reviewed on a regular basis and updated as needed based on requirement changes or regulations.
3. Training and Education: HealthEdge provides various training to its workforce members, including new hire, annual refresher, and role or product-specific training.
4. Reporting: HealthEdge is committed to fostering a culture of compliance, good corporate governance, and ethical behavior and encourages the reporting of improper, unlawful, or unethical behavior. Workforce members are encouraged to discuss any suspected violations with appropriate individuals within HealthEdge. HealthEdge has a strict non-retaliation policy–there can be no retaliation, penalty, or retribution for good faith reporting of any suspected compliance issue.
5. Monitoring & Auditing: Proactive auditing and monitoring of routine business practices is vital for the identification of potential compliance issues. HealthEdge routinely conducts audits and monitors business processes to identify risks. These processes help:

• Ensure compliance with policies and procedures, laws, and regulations.
• Confirm that corrective actions have been implemented.
• Evaluate the overall effectiveness of the compliance program.

6. Enforcement & Discipline: HealthEdge does not tolerate non-compliance with company policies or applicable laws. Any non-compliance could compromise HealthEdge’s operations, the services provided to customers, or its Violations of the HealthEdge Code of Conduct and other policies and procedures require a corrective action and reporting to the appropriate regulatory or law enforcement agency when applicable. HealthEdge has well-publicized disciplinary standards that:

• Prohibit authorization or participation in activities that violate HealthEdge policy.
• Articulate expectations for reporting compliance issues and assists in their resolution of issues.
• Provide timely, consistent, and effective enforcement of the standards when non-compliance or unethical behavior is detected.
• Encourage good-faith participation in the compliance program.

7. Response & Prevention: HealthEdge has a well-developed compliance program, with established procedures, processes, and system implementation for promptly responding to compliance issues. The HealthEdge compliance program ensures that:

• Issues are acknowledged as they arise.
• Potential compliance problems are investigated.
• Concerns are proactively identified through rigorous auditing and monitoring.
• Problems are corrected promptly and thoroughly to reduce the potential for recurrences.

8. Background Checks: In addition to the seven foundational elements of a compliance program outlined above, HealthEdge also incorporates Background Checks that include an investigation of criminal history, exclusions, and reference checks. HealthEdge makes reasonable efforts to ensure personnel and business partners are not engaged in illegal activities or conduct that is inconsistent with an effective compliance program.

Conclusion

Achieving compliance requires a thorough understanding of all applicable laws and regulations, the development of policies and procedures to ensure compliance, the implementation of controls and monitoring systems, and ongoing maintenance and updates to ensure compliance with changing requirements. HealthEdge’s compliance program ensures the company meets established standards, upholds its commitments, protects its business reputation, and avoids financial penalties. By prioritizing compliance, HealthEdge mitigates legal and financial risks, operates ethically, and serves the best interest of its customers.

What Health Plans Should Know as Interoperability Continues to Change the Game for Healthcare

Interoperability has transformed every facet of the healthcare delivery system, creating new opportunities to improve outcomes, reduce costs, and improve efficiencies. It has also been the key to enabling healthcare technology solutions to achieve their full potential.

By gaining a deeper understanding of the origins, current status, and future potential of interoperability, health plans can seize the opportunity to implement modern and innovative care management integration capabilities that deliver results for digital payers.

Defining Interoperability

Interoperability in healthcare refers to the ability of various information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner, in order to provide timely and seamless portability of information and improve the health of people and populations around the world.

Interoperability is the basis on which healthcare providers are able to deliver coordinated and comprehensive care to patients by accessing and sharing critical patient data in real-time. It also enables health plans to streamline administrative processes and reduce costs. As the healthcare industry continues to evolve and adopt new technologies, interoperability will also become an increasingly vital aspect of healthcare delivery and management.

Why Interoperability Matters

Interoperability can have significant positive implications across the healthcare ecosystem. Key goals of seamless integration include:

1. Advancing care coordination: Interoperability facilitates the sharing of member health information between payers, providers and systems, enabling better coordination and collaboration among organizations and teams.
2. Improving outcomes: By providing care managers and healthcare providers with access to comprehensive and up-to-date patient information, interoperability can help care managers create effective care plans and improve patient outcomes.
3. Streamlining administrative processes: Interoperability can reduce administrative burden, support new payment models, and ease claims processing.
4. Reducing costs: Interoperability can help reduce errors, streamline processes, and save time, leading to overall cost savings for payers, healthcare organizations, and members.
5. Improve member satisfaction: By improving data exchange, members have greater access to health and claims information, improving satisfaction and engagement.

The Beginning: Unlock the Power of Health Data through Interoperability

The need for interoperability originated as healthcare providers embraced widespread adoption of electronic health records (EHRs). EHRs were intended to revolutionize the way healthcare was delivered, enabling better coordination of care, reducing medical errors, and improving patient outcomes. However, in practice, EHRs created silos of health data that were not easily shared between providers or patients. This lack of interoperability led to fragmentation of care, duplication of tests, and unnecessary healthcare costs.

Recognizing the need to address these issues, the 21st Century Cures Act mandated that healthcare providers make patient health information available to patients and other providers in a standardized format through open, secure, and standardized application programming interfaces (APIs). The Act also created new provisions for healthcare data privacy and security, ensuring that patient data is protected when it is shared between providers.

These interoperability standards were important for several reasons. First, they empowered patients to take control of their health information and share it with any provider they choose. This increases patient engagement and allows for more comprehensive and coordinated care. Second, the rules helped to break down the silos of health data that had developed, enabling providers to access complete patient records, reducing the risk of medical errors, and improving the quality of care.

Finally, the interoperability rules promoted innovation in healthcare by encouraging the development of new applications and tools that can use healthcare data to improve patient outcomes, reduce costs, and improve efficiencies. Interoperability continues to be a priority for health plans and organizations across the healthcare ecosystem.

New Regulation and Innovation: Key Drivers Influencing Interoperability Today

Today, new regulations and continued innovation are driving urgency for greater interoperability. For example, the CMS Proposed Rule: Advancing Interoperability and Improving Prior Authorization Processes will directly influence integration priorities for many health plans. The proposed rule updates some of the policies included in the Interoperability and Patient Access Final Rule of 2020 and officially withdraws the December 2020 CMS Interoperability proposed rule. The objectives of the policy are to reduce the burden on both payers and providers, improve efficiencies, and advance patient access to health information. Some of the conditions take effect immediately, while others require implementation by 2026. Given the scope, it is important health plans to take action now and prepare their infrastructures for full implementation.

The proposed rule includes multiple requirements for payers that will directly influence their interoperability strategies:

Patient Access API: The rule proposes to require regulated payers to include information about patients’ prior authorization decisions to help patients better understand the process and contribution to their care. The proposed provision would also require impacted payers to report annual metrics to CMS about patient use of the Patient Access API.

Provider Access API: The rule proposes impacted payers build and maintain an API to share patient data with in-network providers where a treatment relationships exists with the patient.

Payer-to-Payer Data Exchange on FHIR: The rule proposes to require payers to exchange member data when a member changes health plans, with the member’s permission. The data elements include claims and encounter data, those identified in the USCDI version 1, and prior authorization requests and decisions – only if the patient opts in to data sharing.

Improving Prior Authorization Processes: The rule proposes a series of policies in an effort to improve the prior authorization process through greater efficiency and transparency.

The rule also outlines CMS’s recommended use of certain implementation guides for the APIs listed in the rule, but does not propose requiring their use.

The provisions outlined in the CMS proposed rule facilitate moving the industry toward more streamlined communication and better information exchange that can benefit members, payers, and providers. As organizations await the final ruling, there are steps that can be taken now to prepare:

1. Understand how the ruling will impact your health plan. Assess guidelines and determine which provisions will apply to your organization.
2. Evaluate your current data management processes. Is all member information available in a single source in order to create the full record required? If not, what changes need to be made to maintain a record for each member?
3. Evaluate your current interoperability strategy. How is member information exchanged between payers, providers, and patients today? How is prior authorization information managed and exchanged today? In what format are the data points being requested and can they easily be delivered via a Patient API or Provider API?
4. Assess resource availability. Who will be responsible for implementing the new standards? Who will be responsible for ensuring data is available to patients and providers within defined timeframes? What processes will need to change in order to accommodate the new standards?

Future State: Interoperability Considerations for Digital Payers

The proposed rule could be considered just the beginning for innovation in interoperability that will impact health plans moving forward. Rapidly evolving regulatory requirements, new payment models, rising consumer expectations, and new market opportunities will continue to drive payers to advance interoperability. The results promised by continual digital advancements across the healthcare ecosystem rely on seamless data exchange. In fact, interoperability can be considered a prerequisite for many health innovations.

Digital payers should consider their care management system’s ability to meet key requirements for modern and evolving integration criteria:

1. Exchange a variety of data types: Health plans should ensure their care management system can access, ingest, and exchange various data types across other systems with industry interoperability standards.
2. Support real-time data exchange: Informing decisions in a timely manner is critical when it comes to effective care management. Health plans should ensure care managers have real-time access to member information.
3. Work seamlessly with other systems and data sources: Care management systems function as the core orchestrator of member care. But the most effective care plans rely heavily on data from multiple sources to inform optimal care plans. In addition, care management systems must work in tandem with claims, payment integrity, and other administrative systems to streamline processes and reduce costs.

GuidingCare® enables digital payers to meet these modern interoperability needs, plan for future requirements, and support continued innovation. To learn more about how about creating a successful interoperability strategy with GuidingCare, visit the GuidingCare page on the HealthEdge website.

In recent years, Medica, a Minnesota-based non-profit health insurance provider, has experienced explosive growth. To keep up with its growth, Medica’s was using HealthEdge’s core administrative processing system (CAPS), HealthRules^® Payer, which had resulted in multiple instances of the system.

However, the growing complexity of the multiple configurations led to the need for a more efficient way to manage the HealthRules Payer infrastructure, and Medica turned to the experts within the HealthEdge team for guidance.

Medica faced two main challenges: Firstly, the company needed to create new efficiencies to help reduce complexities and administrative burdens associated with maintaining multiple HealthRules Payer environments, reducing the time spent on issue research and resolution, enabling faster system audits, and improving tracking of configuration changes to support more seamless configuration changes. Secondly, the company needed to maintain quality, reducing occurrences of early promotion of another user’s work related to multi-user risks of promoting someone else’s work and eliminating the risk of wiping out another user’s changes.

The outcome of this collaboration was the creation of HealthRules Promote, a web-based application that all HealthRules Payer customers can now use to manage complex configurations and multiple instances of the solution. Medica noted that the collaborative effort between the two teams resulted in a powerful solution that helped the company support more than 400 configuration projects in the past year.

HealthRules Promote provides insight into the complexities of HealthRules Payer configuration and ensures that all unique dependencies are considered prior to promoting the configuration to production. It also allows multiple users across multiple lines of business to control and understand which users’ configurations are ready for promotion and which ones have conflicting dependencies.

For Medica, HealthRules Promote provides delivers several meaningful benefits:

1. The solution saves time through configuration artifacts by removing the need to create and maintain exports, eliminating separate spreadsheets for tracking, and easily importing configuration sets to new environments in just a few clicks.
2. The solution allows the company to confidently migrate configurations without errors that ultimately cause problems in production.
3. The dependency-and-compare features of HealthRules Promote allow Medica to easily audit builds across environments and identify development changes over time that may be causing product issues.

To explore how HealthRules Promote can empower your organization with actionable insights into the complexities of your multiple HealthRules Payer configurations, visit the HealthRules Promote page on the HealthEdge website or email [email protected].