How to create a healthcare experience that breaks all boundaries

Healthcare players that embrace AI and modern platforms can deliver healthcare experiences that span organizational, physical and digital boundaries.

Today’s healthcare experience should extend beyond the boundaries of any single organization. Consumers expect to receive care almost anywhere; consult health experts through their smartphones; use their wearables and in-home devices as health sensors; and get help from brokerages to manage their health savings accounts. The effects of COVID-19 have amplified these trends, as more and more consumers view elegantly blended experiences across digital and physical channels as the new normal.

Organizations that digitize, orchestrate and own the consumer healthcare experience across entities, devices and channels will be best positioned to build market share and consumer loyalty. Getting there will require a modern platform and data to accommodate advanced forms of artificial intelligence (AI) and machine learning (ML) models that deliver hyper-personalized consumer experiences and services.

Tools for boundaryless healthcare experiences

Forward-looking healthcare organizations are applying these capabilities in pursuit of these goals. Here are three examples of the work under way:

• Digitization to transform the consumer experience. By digitizing manual processes, such as member enrollment, provider network updates, preauthorizations, claims editing and more, healthcare organizations can increase speed, throughput and accuracy. Doing so can also make it easier to create workflows that span internal and external systems, such as claims, electronic health records, remote monitoring devices and other industry platforms.

We worked with one of our clients to automate its pre-authorizations for in-state providers by extending its TriZetto® Facets® core administration platform, which provides real-time claims processing and event-driven data streaming. Event-driven data streaming delivers the right data, where and when it’s required. With Facets, providers can submit preauthorization requests and receive responses virtually instantaneously.

The real-time claims in Facets can calculate a financial estimate for the plan’s members based on their personal deductible status, co-pays and co-insurance. With this up-to-the-minute data, our client can enable its members and physicians to make fully informed decisions right at the point of care. This is a huge improvement from the usual healthcare experience of waiting several days to learn if a preauthorization has been approved, or members receiving incomplete information about their financial responsibility.

• Hyper-personalization through data modernization and AI. Core administration systems create literally millions of data points each day. Using AI tools, such as ML models and predictive analytics, healthcare organizations can utilize that data to anticipate and proactively offer what an individual health consumer will want or require.

When AI engines and ML models are integrated into transaction streams, they can provide real-time predictive insights into individual members’ issues while preserving revenue and optimizing costs. These intelligent systems can, for instance, prompt service representatives to offer the specific benefit that retains a member’s business, or alert care managers on how to intervene to avoid hospital readmissions. They can also reduce member and provider friction by adjusting claims in real-time that would otherwise pend.

To deliver more individualized services to its members, a large health plan is building out a data hub using Facets data orchestration and event-driven data publishing. The data ecosystem will incorporate data from applications and systems across the business. Using the platform’s event-driven publishing, the health plan can stream data to other, complementary systems as an event occurs, such as a processed claim or preauthorization. The platform can also ingest data from other systems, normalize it and publish to other systems in real time.

• Modernizing core systems. Increasingly, our clients recognize that advanced process digitization and hyper-personalization must be built on modern, open, cloud-based core platforms to accelerate time to market. Because our core systems are architected around cloud-optimized technology such as micro-services, containerization and low- and no-code operating environments, clients can easily integrate best-of-breed applications and use application programming interfaces (API) that connect to functionalities residing on third-party systems.

One such client, a large national payer organization, recently updated and migrated its core TriZetto® QNXT® administrative system to the cloud — running on Microsoft Azure. By moving its core platform and data center to the cloud, the organization will be able to reduce costs and enable regional plans to access system updates as they roll out. Before the cloud migration, hundreds of physical servers had to be updated in multiple geographies, resulting in patchwork rollouts of features and services and complex operations management. With its new cloud efficiencies, the organization has gained flexibility and operational excellence, enabling it to expand its government and value-based care programs.

Investing in hyper-personalization via AI and modern platforms is a no-regrets decision for healthcare organizations. With these capabilities, they can improve consumer outcomes and experiences, and elevate financial performance in the near term. Healthcare players that embrace these disciplines are better positioned to reach their full potential and create sustainable new value by delivering experiences and services that seamlessly span organizational, physical and digital boundaries.