Pegasystems Launches Care Management Solution To Improve Patient Care While Cutting Healthcare Costs

CAMBRIDGE, Mass. July 28, 2008 – Pegasystems (NASDAQ: PEGA), today introduced its Care Management Workflow Framework (CMF), a patient-centric business process management solution that automates the creation and on-going improvement of personalized care management programs. By unifying disease management, case management, and utilization management across the healthcare enterprise, CMF gives care professionals the ability to collaborate in real-time and in turn provides patients with an equally cohesive view of their personal care plans. CMF reduces overall complexity, cuts utilization costs, and reduces cost of care management program development by 40-60 percent. These efficiencies are especially needed now as the healthcare system faces a tidal wave of aging baby boomers, more likely to demand and respond well to proactive care programs.

Built on Pegasystems’ industry-leading SmartBPM® platform, CMF gives healthcare organizations the flexibility to manage an unlimited number of population groups with high-touch care programs for those with chronic, acute-episodic and acute-complex needs. CMF was designed to ease the burden of managing changes, such as new clinical protocols or government regulations, without interrupting on-going and highly customized care programs.

“Differentiation among payers is shifting to how well they care for members, and many are just not able to meet the growing demands in care management because not only are their processes are broken -- they have inflexible technology,” said Joanne Galimi, Research vice president of Gartner Inc.  “Payers need flexible, user-friendly systems that provide workflow and rules-engine capabilities.  BPM technology helps automate and manage all the key processes within the care management continuum.” 

Key benefits of CMF include:

  • 360 degree view of patient – a dynamic patient record that provides real-time information across pertinent care plans and data sources including demographic, clinical, claims, authorizations, correspondences and notes; 
  • Visual timeline for care management – gives care managers at-a-glance view of progress and status, displaying all scheduled patient care management events including phone calls, assessments, outgoing correspondence, materials, and processing steps across all active care plans;
  • Automated care plans – guides and automates the creation and customization of care plans; 


  • Intelligent alerts – searches through relevant data sources and systems to see if warnings are needed and determines whether necessary conditions have been met (lab values, weight targets, and treatment adherence).  It automatically triggers next-steps, sending tasks, correspondence, literature or notifications to all parties;
  • Industry standards – comes with pre-configured database support for lab results, medications, and risk assessments; includes typical roles (member, provider, etc) and typical work (claims, authorization and clinical codes including ICD-9, CPT, HCPCS and NDC).  Also includes HIPAA x12 EDI support for multiple message including 278 (authorizations) and decision support for straight-through-processing of utilization requests.

“Traditional care management technologies provide clinical content, but do not always help the care team and patients work effectively together,” said Elizabeth Hart, senior director of Healthcare Solutions at Pegasystems.  “This adds cost, wastes time, degrades the quality of care, and makes it impossible to offer customized programs. CMF fixes this problem at a time when payers anticipate an ever-increasing influx of aging baby boomers needing care.”  

Pegasystems’ CMF solution maximizes the efficiency of care management professionals through its intelligent decisioning and patient-centric workflow.  CMF automates high-volume transactions such as pre-authorizations and pre-certifications for healthcare services, allowing skilled staff to focus on higher value-added and personal care management functions.  Well-suited for complex cases, CMF drives collaboration through the coordination and sharing of information across communication channels throughout the care management team and the patient’s support network. 

Pegasystems’ healthcare solutions are widely-used by major healthcare organizations including three of the top five US health plans and more than 50 percent of the Blues network, representing over 100 million covered lives.  To find out more about Pegasystems healthcare offerings visit

About Pegasystems

Pegasystems (NASDAQ: PEGA) develops strategic applications for marketing, sales, service, and operations. Pega’s applications streamline critical business operations, connect enterprises to their customers seamlessly in real-time across channels, and adapt to meet rapidly changing requirements. Pega’s Global 3000 customers include many of the world’s most sophisticated and successful enterprises. Pega’s applications, available in the cloud or on-premises, are built on its unified Pega 7 platform, which uses visual tools to easily extend and change applications to meet clients’ strategic business needs. Pega’s clients report that Pega gives them the fastest time to value, extremely rapid deployment, efficient re-use, and global scale. For more information, please visit us at

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The information contained in this press release is not a commitment, promise, or legal obligation to deliver any material, code or functionality. The development, release and timing of any features or functionality described remains at the sole discretion of Pegasystems, Pegasystems specifically disclaims any liability with respect to this information.


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