Healthcare organizations have more personal and public health data at their disposal than ever before, with more still to come as the Affordable Care Act pushes for widespread implementation of electronic health records (EHR). Health information systems managers face challenges in finding the best ways to store and secure this data. But perhaps the bigger challenge with health information systems is operationalizing the data that they contain—putting it to work to improve health outcomes and related services.
Many progressive healthcare organizations, including most of the top U.S. health plans, are turning to business process management (BPM) software from Pega to help them derive more operational value from their health information systems.
Health Information Systems Integration and Operationalization
Pega integrates heterogeneous data sources and systems and puts them into the service of automated business processes that reduce operational costs while improving performance. Using Pega doesn’t require a “rip and replace” of legacy health information systems; rather, the Pega BPM platform “wraps and renews” existing systems and integrates them into a unified healthcare management system that delivers the right information to the right people, at the right time.
Core capabilities of Pega healthcare management technology include:
- Dynamic case management that provides complete visibility into and managerial control over a case—such as a customer inquiry, a claim, or a patient receiving long-term care—across all relevant systems and processes, throughout the case lifecycle.
- Workflow automation, including rules-based routing, prioritization, and escalation.
- Embedded predictive analytics, enabling healthcare organizations to parlay insights from “big data” into personalized customer services and offers.
- Automated decisioning based on configurable business rules, to enable straight-through processing (for a customer service inquiry or a claim, for example) whenever possible; and to provide decision support for service representatives or healthcare providers when straight-through processing isn’t possible.
- Pega Build for Change® technology, which enables business users to design and implement key health management system features without having to do any coding.
Pega Solutions for Operationalizing Health Information Systems
Pega offers purpose-built healthcare software systems that solve some of the key operational challenges faced by today’s healthcare plan providers. Each Pega healthcare management solution runs on the Pega BPM platform, and each supports standards-based integration with legacy health information systems so that existing data repositories can be incorporated into modernized business processes.
Pega healthcare software solutions include:
- Benefits and Products Development
- Sales and Enrollment
- Customer Service
- Marketing and Retention
- Care Management
- Claims Processing
- Medicare and Medicaid
- Appeals and Grievance