Healthcare Information Technology: IBM Health Integration Framework

The IBM Health Integration Framework: Accelerating solutions for smarter healthcare The IBM Health Plan edition

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2 The IBM Health Integration Framework: Accelerating solutions for smarter healthcare

Today’s health plan executives and government health insurers must guide decision making in what is arguably the most complex IT system in any industry.


Addressing the challenges of a rapidly changing environment Healthcare technology has advanced to unprecedented levels, but dramatic changes in the business and political climate are making it hard for health plans to keep pace. Today’s health plan executives and government health insurers must guide decision making in what is arguably the most complex IT system in any industry.

Despite significant progress over the past decade, health plan line-of-business executives continue to focus on ways to automate the manual processes that drive up administrative costs and contribute to increasing premiums. To achieve mem-bership targets, health plans must be able to respond quickly to opportunities and competitive threats, and they must be able to comply with significant regulatory requirements and mandates.

For health plan IT decision makers, legacy systems often mean limited business flexibility. IT resource constraints inhibit the company’s ability to rapidly introduce and absorb change; the IT staff cannot code fast enough to keep up with the demand. Clearly, the point-solution approach no longer works. Adding to these pressures, evolving regulations and standards present significant challenges: code set changes, for example, require periodic system, process and procedure overhauls.

For health plan consumers, buying patterns are changing as a result of high unemployment and coverage mandates. Rising premiums are leading employers to shift financial accountabil-ity to employees. Members and providers are demanding more transparency of costs. Consumers and politicians are focused on health insurance firms’ financials.

The solution to these challenges is multi-faceted. In broad terms, to move toward smarter healthcare, health plans have to focus on value, core processes and collaboration—concentrat-ing on what they do best and doing it more efficiently. Health plans need to exploit opportunities to form new partnerships and build future capabilities. And they need to act with speed to institute change, set leadership agendas and manage risk and performance with transparency.

Most health plans today look at claims or at their environment from a plan perspective, from an employer perspective, from a group perspective—almost every perspective except the member. But that is about to change.

Today’s challenges to health plans call for business transformation—a shift away from a product business model and into a service model. The individual healthcare member is now the customer.

To help you make a successful transition from a product model to a service model, IBM® and IBM Business Partners offer solutions built on the Health Integration Framework—solutions that include enterprise health analytics and core systems modernization.


The IBM Health Integration FrameworkThe IBM Health Integration Framework is a unified software platform for implementing comprehensive solutions for healthcare providers, health plans and life sciences enterprises to improve safety and quality of care, process efficiency and patient and member satisfaction.

The IBM and IBM Business Partner assets that comprise the Health Integration Framework reflect more than 10 years of success in the healthcare industry. The framework offers a superior approach to the two traditional practices of custom development and packaged applications use. Custom development can be both lengthy and expensive, while pack-aged applications are frequently inflexible, stand-alone, and require heavy customization.

The framework enables you to choose from a variety of industry solutions that are pre-integrated on common middleware and industry-specific extensions. As a result, you can quickly deploy solutions using your existing health IT investments in your current environment— and at lower cost—without compromis-ing flexibility and choice.

The IBM Health Integration Framework delivers:

• Speed: Incorporating a proven software foundation, healthcare industry-specific extensions, pre-built solution accelerators and implementation patterns for faster deployment at lower risk.

• Flexibility: Providing a roadmap that enables customers to build capabilities over time on their existing environment.

• Choice: Leveraging an ecosystem of industry independent software vendors (ISVs) and IBM solutions that are built on industry standards and integrated into the framework.

• Interoperability: Increasing transparency between healthcare entities for more efficient information sharing, service coordination and record keeping.


Industry-specific extensions and acceleratorsService oriented architecture (SOA) is a business- centric IT architectural approach that supports integrating your business as linked, repeatable business tasks, or services. With the Smart SOA approach, you can find value at every stage of the SOA continuum, from departmental projects to enterprise-wide initiatives.

On top of the IBM SOA foundation, the framework’s healthcare-specific assets, called extensions and accelerators, add industry relevance and open stan-dards, integrate faster with legacy systems, build new services and provide new capabilities. These assets include:

• IBM InfoSphere™ Clinical Analytics: An integrated data warehouse platform that provides a single source of trusted administrative, clinical and research information throughout the healthcare enterprise to help improve operational efficiency and outcomes.

• IBM WebSphere® Message Broker with support for HL7: An advanced Enterprise Service Bus providing connectivity and universal data transformation for assured delivery and message interchange between multiple applications.

• IBM WebSphere Transformation Extender Industry Pack for Healthcare: Capabilities to help integrate a range of industry-standard data formats with your enterprise infrastructure; supports HIPAA EDI (including 5010, HL7 and NCPDP), leveraging predefined templates, tools, and conversion and validation maps to reduce risk.

• IBM WebSphere Healthcare Content Pack: Rich set of assets for enrollment, case management, employer and group management, claims management, and provider collaboration solution areas.

Combining strengths in partnershipThe IBM Health Integration Framework includes an ecosys-tem of independent software vendors and systems integrators to provide a wide range of healthcare applications that are proven to run on the framework. This means faster deployment, easier integration, lower cost of operations, and an ever-expanding partner community.

With the help of IBM solutions, leading health plans are improving the ways services are administered and operations are organized. IBM solutions are contributing to smarter, more efficient and effective healthcare operations in two important categories: enterprise health analytics, with solutions for health plan analytics and consumer health information; and health plan core systems modernization, with solutions for model-driven architecture and business process re-engineering, health plan customer service modernization, and electronic data interchange (EDI) modernization.


Enterprise health plan analyticsIBM enterprise health plan analytics provide aggregation and analysis of information from disparate systems throughout the enterprise. These solutions detect patterns in sales, mem-bership, claims and providers. With this data, health plans can create and modify products and services, minimize fraud and improve profitability. For health plans, the data provide the ability to:

• Find and mine sales and prospect information for cross- or up-selling to existing or new corporate and individual customers.

• Consolidate member information siloed in multiple applications.

• Unlock valuable insights from unstructured clinical data by gathering, analyzing and structuring content and transforming it into actionable information.

• Leverage unstructured text analytics to streamline medical review and transform unstructured clinical data into quantifiable coding, providing deeper insight into provider quality measures and automated review of evidence-based protocol compliance.

• Predict and deliver needed services to optimize costs and wellness.

• Improve the costly, error-prone process of entering member information into multiple transaction systems.

• Manage evolving business relationships with members (such as births, retirements) for improved member retention.

IBM industry-specific software, accelerators and best practices can help you manage costs, improve safety and quality of care, achieve operational efficiency, and improve member satisfaction.

Solutions built on the IBM Health Integration Framework include:

• Health plan analytics – Detects patterns in sales, membership, claims and providers to create and modify products and services, minimize fraud and improve profitability.

• Consumer health information hub – Consolidates information from disparate sources to build a single view of a member or provider, delivering member-centric services and improved member retention.

• Core systems modernization – Transforms core health insurance systems through integration and process orchestration to increase worker productivity, improve deployment of new services and enhance customer service.

• HIPAA 5010 and ICD-10 conversion - Speeds conversion to HIPAA 5010 and ICD-10 code sets and modernizes transaction handling.

• Health plan portals – Provides members and employees with access to information and self-service to reduce costs for customer service, facilitate collaboration and increase satisfaction.


Case study: Major U.S. health plan gains competitive edgeA not-for-profit managed care provider serving more than two million members needed targeted offerings to help differentiate itself from competitors and win new business. The health plan provider offers PPO and traditional indemnity health insurance plans. The company wanted to respond efficiently to the growing information needs of customers and providers. To achieve this goal, the plan provider needed a sin-gle view of information across their multiple lines of business, with business intelligence capabilities.

According to the company’s chief information officer, informa-tion management was critical to the company’s ability to serve customers—a real differentiator in the marketplace. “We must have the right information in place for people to be able to make the best choices for their own healthcare.”

To gain a competitive edge, increase productivity and improve quality of service to customers and healthcare providers, the plan provider turned to IBM to help deliver timely and seamless access to information.

The solution included:

• IBM InfoSphere Information Server to profile, transform, and load data to their enterprise data warehouse.

• IBM DB2® for AIX® and IBM InfoSphere Warehouse to accommodate 1TB of raw data and 100 concurrent users.

• IBM Cognos® BI for multidimensional analytics and client reporting.

• IBM OmniFind® and IBM DB2 Content Manager for unstructured data.

Smarter business outcomesThe scalable enterprise data warehouse solution provided powerful multidimensional analytics and access to structured and unstructured information. The solution:

• Improved customer and provider satisfaction by enabling them to run their own analytics and better manage their healthcare costs.

• Reduced risk with improved tracking of data movement to comply with healthcare regulations.

• Reduced time to load data into the data warehouse and improved performance for high-volume data transformations.

• Provided access to structured and unstructured data—historical and real-time.

“By lowering our internal costs in the reporting area and giving us additional capabilities, the IBM solution has offered us a competitive edge, enabling us to go after prospects that we couldn’t bid on in the past,” says the company’s director of client management.

The chief data architect concurs: “We needed a set of integrated tools that would provide a seamless interaction with our customers. IBM’s Information on Demand tools provide access to both structured and unstructured data, both historical and real time. IBM’s vision for Information Management is very important to us.”

Key technologiesIBM Information Server DataStage® Enterprise EditionIBM DB2IBM DB2 Content ManagerIBM OmniFind Enterprise Edition


Case study: Health plan improves operational efficiency A U.S. health plan needed to improve the functionality and reporting capabilities of its enterprise data warehouse. As part of this strategic priority, the organization wanted to consolidate data from four claims engines into a single database manage-ment system (DBMS) environment. They also wanted to improve the reporting process for major accounts.

To achieve their goals, the health plan brought in IBM Business Intelligence consulting to assess and then implement the evolution to new architecture. Initial milestones included creating a common claim operation data store (ODS) and pro-vider credential ODS which comprised the integral part of the enterprise data warehouse architecture for claim management and provider management. The team also established an efficient reporting environment for major accounts.

Smarter business outcomesThe solution enabled the health plan to:• Increase flexibility in the dynamic healthcare environment.• Improve response and capability for internal and external

information customers.• Enhance the company’s operating efficiency.• Continue to build an information foundation to support

more efficient and cost effective medical care.• Enhance analytic comparison across the enterprise.

Enterprise health plan analytics—a foundation for quality care Our enterprise health plan analytics solution embeds accelerators that are part of the IBM Health Integration Framework, creating operational flexibility, helping to accelerate solution deployment and ensur-ing healthcare solution integration. The solution uses building blocks such as:

• IBM Cognos 8 BI • IBM WebSphere Portal UI• IBM InfoSphere server • IBM InfoSphere Information Server • IBM InfoSphere Data Architect • IBM InfoSphere Balanced Warehouse® • IBM InfoSphere Clinical Analytics • Initiate Payer Data Management• Health Plan Data Model• DB2 Data Warehouse• Medical Records Text Analytics (MRTA)


Health plan core systems modernizationIBM health plan core systems modernization provides the transformation of core health insurance systems. Transformation is achieved through integration and process orchestration to increase worker productivity, enhance customer service, and improve overall efficiency and flexibility in creating and deploying new services—for example, claims process transformation or member enrollment.

Case study: EDI modernization helps solve performance issues and improve provider relationsA large health plan that serves more than 3.2 million members needed to prepare for new HIPAA regulations mandating migration to the ANSI 5010 format for EDI, which was also required for another regulatory mandate, ICD-10. To comply with these mandates, the company would need major upgrades to their existing infrastructure.

The IBM Lab Services team, along with IBM Global Technology Services infrastructure team, demonstrated deep understanding of the health plan’s EDI needs and regulatory requirements, including mandated HIPAA transactions and ICD-10 requirements. IBM worked with a Business Partner, Edifecs, Inc., to create the solution architecture and roadmap. IBM performed a pilot that validated the architecture and dem-onstrated the capabilities and integration of the EDI solution.

Smarter business outcomesModernization of the company’s EDI gateway delivered a foundation for streamlining and improving the reliability of the company’s EDI processes and workflows, helping solve performance issues and improve provider relations. The solution also delivered a foundation to comply with HIPAA 5010 and ICD-10 mandates.

Key technologies WebSphere Transformation Extender with HIPAA PackWebSphere Partner GatewayWebSphere Application Server NDWebSphere Message BrokerIBM Tivoli® Composite Application Manager for SOA

Case study: Health plan improves time-to-market, reduces costsA major health plan serving more than six million members nationwide needed to improve their management of large volumes of documents, both in electronic and in paper formats. The storage, indexing, retrieval and workflows of these docu-ments did not follow a standard process or technology platform throughout the firm. As a result of the company’s growth through acquisitions, there were various information silos with multiple, non-integrated technologies.

Smarter business outcomesNow, with business process modernization, the company is better able to control costs through improved integration and efficient use of imbedded data compression. Thanks to IBM FileNet® Lab Services and IBM Global Business Services, the company can now use advanced data mining for medical management to help control the cost of care.

Key technologies IBM FileNet P8


Case study: Modernized EDI gateway lays the foundation for complianceA large health plan that serves more than 2.8 million members was faced with an aging EDI infrastructure and needed to comply with HIPAA 5010 and ICD-10 mandates.

Smarter business outcomesIBM Business Partner, Edifecs, Inc. modernized the company’s EDI gateway and channel architecture, laying the foundation for compliance with HIPAA 5010 and ICD-10 mandates. The new infrastructure prepares for migration to stream based transactions, such as HL7.

Key technologiesWebSphere Message BrokerWebSphere Transformation Extender with HIPAA PackWebSphere Partner Gateway

Core systems modernization—the way to flexibility Core systems modernization enables business leaders to define business processes and use enabling tech-nology that will drive the metrics and business results required by a health plan. Solution components for core systems modernization include:

• Health plan data model• Data warehouse and management services• Single view (member health)• Healthcare analytics/business intelligence• IT and infrastructure optimization• Member-centric operations integration

IBM skill sets include:

• Core systems operations and process redesign• Business information requirements definition• Information architecture and integration to

business• Application management and maintenance


Why IBMIBM’s deep industry expertise provides the foundation for solving the most complex problems in the delivery of healthcare and health plans. A leader in working with and transforming healthcare organizations through service oriented architecture (SOA) and information management, IBM employs dedicated technology research professionals, including the largest clinical consulting staff in the United States. With its long-term commitment to industry standards, IBM has developed proven business transformation and health analytics methodologies and global delivery capabilities.

For more informationTo learn more about the IBM Health Integration Framework, contact your IBM representative or visit: ibm.com/software/industry/healthcare/

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Produced in the United States of America June 2010 All Rights Reserved

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Healthcare Information Technology: IBM Health Integration Framework

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